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Cftbtmbia  Umbertfttp 

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l&tUvtni?  ffitbrarg 


AN   INDEX   OF    SYMPTOMS 


AN  INDEX  OF  SYMPTOMS 


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http://www.archive.org/details/indexofsymptomswOOIeft 


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AN 

INDEX  OF  SYMPTOMS 

WITH    DIAGNOSTIC    METHODS 


BY 

RALPH    WINNINGTON    LEFTWICH,  M.D 

LATE   ASSISTANT-PHTSICIAN   TO   THE   EAST  LONDON  CHILDREN'S  HOSPITAI 

AUTHOR  OF  '  TABULAR  DIAGNOSIS,'  '  A  POCKET-BOOK  OF  TREATMENT  ' 

1  STPHONAGE   IN  THE  LARGE   INTESTINE,'  ETC. 


Nihil  humani  a  me  alienum  puto 


FIFTH     EDITION 


NEW   YORK 
m  WOOD  &   COMPANY 
MDCCCCXV 


PRINTED   BY 

SPOTTISWOODE   AND  CO.   LTD.,   COLCHESTER 

LONDON   AND   ETON,    ENGLAND 


i 


PREFACE 

TO 

THE  FIFTH  EDITION 

The  present  edition  contains  a  large  number  of  new  symptoms 
and  many  new  tests,  while  the  interlineary  notes  have  been  much 
amplified.  Further,  an  attempt  has  been  made  to  devise  a 
scientific  classification  of  symptoms.  The  increase  in  matter 
has  involved  an  increase  in  bulk,  so  that  it  is  no  longer  a  pocket 
book,  but  a  book  for  the  desk. 

The  author  is  gratified  to  find  his  work  so  much  in  use  by  all 
classes,  from  the  clinical  clerk  to  the  clinical  lecturer.  It  is  not 
always  that  pioneer  work  meets  with  prompt  recognition. 

R.  W.  L. 
H6  Ebury  St.,  Eaton  Sq. 
London,  S.W, 


Pfi  EFACE 

TO 

THE    FIRST    EDITION 
(Abridged) 

The  physician,  in  endeavouring  to  make  a  diagnosis,  seizes 
first  upon  a  few  prominent  features,  which  will  enable  him  to 
say  that  the  disease  is  one,  of,  perhaps,  a  dozen.  He  then  looks 
carefully  for  further  symptoms,  and  these,  by  a  process  of 
exclusion,  gradually  point  to  but  one  ailment.  Should  he  find 
himself  at  fault,  and  conclude  that  no  disease  with  which  he 
is  f amiliar  is  consistent  with  the  particular  grouping  of  symptoms 
in  the  case  before  him,  he  naturally  refers  to  his  books.  Here  he 
meets  with  a  fresh  difficulty  ;  for,  in  his  text-books  of  medicine, 
in  his  Dictionary  of  Medicine,  and  even  in  his  Handbook  of 
Diagnosis,  he  finds,  with  rare  exceptions,  that  diseases,  not 
symptoms,  form  the  headings ;  the  order  being  therefore  the 
exact  reverse  of  that  which  takes  place  in  his  own  brain.  He 
has  consequently  to  wade  through  page  after  page  and 
book  after  book  before  he  succeeds,  or  is  satisfied  that  he  has 
failed,  in  the  object  of  his  search.  But  in  the  present  work  the 
symptom  forms  the  heading,  and  the  diseases  in  which  that 
symptom  occurs  are  placed  under  it.  A  mere  glance,  therefore, 
will  often  furnish  the  missing  clue. 

It  must  not  be  supposed  that  each  symptom  is  met  with 
constantly  in  all  the  diseases  placed  after  it.  The  author's 
presumption  is  that  the  physician  in  a  difficulty  is  asking  the 
question,  '  To  what  disease  or  condition  may  this  symptom 
point  ?  '  An  attempt  has  been  made  to  indicate  in  some  measure 
the  relative  frequency  of  occurrence,  and  by  other  information 
to  assist  in  differential  diagnosis.  The  word  '  symptom,'  it 
is  scarcely  necessary  to  say,  is  taken  in  its  broadest  sense,  and 
includes  every  factor  in  the  diagnosis. 

R.  W.  L. 

London. 


CONTENTS 

(The  numbers  refer  to  the  sections) 


Art  of  Diagnosis 

1 

Vision 

.  544-565 

Classification  of 

Nose 

566-586 

Patients 

2 

Smell 

.  587-590 

Fallacies 

3-11 

Mouth    . 

.       591-625 

Classification  of 

Teeth 

.  626-635 

Symptoms 

11a 

Palate 

636-640 

INTERRO  GA  TION 

Tongue 

.  641-671 

Sex 

12-13 

J    Taste 

672-675 

Age 

.    14-23 

j    Throat 

.   676-691 

Occupation 

24-27 

<    Swallow 

692-693 

History 

.   28-41 

\    Larynx 

.   694-7US 

Propagation 

42-50 

Neck 

709-736 

Duration 

.   51-54 

Chest 

.   737-768 

Sleep 

55-66 

Breast    . 

769-776 

Appetite 

.   67-70 

Paracentesis 

.   777-805 

Thirst 

-72 

Back 

806-817 

Menstruation 

.   73-84 

Abdomen  . 

.  818-840 

Pain 

85-153 

Limbs 

841-912 

Tenderness    . 

154-187 

Joints 

.   913-920 

Algesia     . 

188-197 

Genitals 

921-935 

Sensation 

198-231 

Urination 

.   936-948 

Weakness 

232-235 

Urine     . 

.     949-1076 

Rigors   . 

236-239 

Bowels 

1077-1084 

INSPECTION 

Stools   . 

.   1085-1108 

Pulse 

240-270 

Vomiting   . 

1109-1138 

Arterial  Tension 

271-275 

Sputa 

.   1139-1191 

Sphygmograph 

276-282 

Cough 

1192-1197 

Pulsation 

283-289 

Breath 

.    1198-1202 

Temperature 

290-306 

Breathing 

1203-1225 

Nutrition 

307-312 

Voice 

.    1226-1234 

Skin 

313-356 

Speech 

1235-1255 

Head 

357-383 

Writing 

.   1256-1260 

Face 

384-409 

Intellect 

1261-1271 

Expression 

410-416 

Emotions 

.    1272-1280 

Ears 

417-430 

Decubitus 

1281-1289 

Hearing    . 

431-450 

Gait 

.   1290-1302 

Eyes 

451-534 

Ataxia 

1303-1304 

XI 


Xll 


CONTENTS 


Paralysis 
Reflexes  . 
Parergi^e 
Spasm 

Electrical  Re- 
action 
Blood 
Bacteria 


PALPATION 


Lungs 
Heart 
Abdomen 
Uterus 


1305-1356 
1357-1395 
1396-1405 
1406-1433 

1434-1447 
1448-1494 
1495-1585 

1586-1591 
1592-1607 
1608-1642 
1643-1656 


PERCUSSION 

Lungs         .         .        1657-1688 
Heart  .  .   1689-1694 

Abdomen,  etc.    .        1695-1714 


AUSCULTATION 


Lungs 
Heart    . 

Vessels,  etc. 


1715-1744 
1745-1771 
1772-1802 


MISCELLANEO  US 


Time  and  Season  . 

Tropical  Diseases 

Radiography 

Tuberculin  and 
other  Tests 

Symptoms — Com- 
plex 

Synonyms 

Index 


1803-1809 

1810 

1811-1814 

1815-1828 

1829 

.   1830 

.     p.  491 


ILLUSTRATIONS 

FIGURE 

1.  A  Classification  of  Symptoms  . 

2.  Points  of  a  Sphygmogram    . 

3.  Typical  Sphygmograms 

4.  Types  of  Temperature 

5.  The  Venous  Pulse    . 

6.  A  New  Regional  Chart 

7.  The  Viscera  from  Behind 

8.  Urinary  Crystals 

9.  Urinary  Casts   .... 

10.  Segmental  Areas  of  the  Cord 

11.  Localisation  of  Reflexes 

12.  The  Viscera  from  the  Front 

13.  Cardiac  Dullness     . 

14.  Heart  Murmurs   .  ... 


Frontispiece 


PAGE 

103 
105 
108 
224 
229 
241 
300 
305 
375 
376 
420 
447 
461 


AN 

INDEX  OF  SYMPTOMS 

INTRODUCTION 

Diagnosis  is  the  most  difficult  part  of  the  art  of  Medicine, 
and  he  who  would  excel  in  it  must  be  well  equipped  both 
intellectually  and  physically.  His  ear  must  appreciate  the 
finest  distinctions  of  sound  in  intensity,  pitch,  and  tempo  ; 
his  eye  must  note  every  variation  in  outline,  movement,  and 
colour  ;  his  sense  of  touch  must  distinguish  every  little  differ- 
ence of  surface  and  form,  and  even  his  sense  of  smell  must  be 
well  developed.  Further,  in  addition  to  the  natural  employment 
of  his  senses,  he  must  be  skilled  in  the  use  of  the  various  instru- 
ments and  devices  which  have  been  introduced  for  the  extension 
of  their  scope.  On  the  intellectual  side,  his  powers  of  judg- 
ment and  comparison  must  be  considerable  ;  for  it  is  not  only 
by  a  knowledge  of  all  the  symptoms  of  a  given  disease  that 
a  correct  diagnosis  is  made  ;  it  is  necessary  also  to  apportion 
due  weight  and  value  to  each  symptom.  But  there  is  still 
another  faculty,  the  possession  of  which  is  indispensable  to 
the  physician  who  would  deal  successfully  with  a  new  problem 
or  a  new  combination.  This,  the  mind's  eye,  will  enable  him 
to  form  a  clear  mental  picture  of  the  various  parts  and  organs 
of  the  body,  not  as  he  sees  them  in  the  dissecting-room  or  the 
post-mortem  theatre,  but  as  they  are  in  life  with  all  their 
functions,  their  movements,  and  their  interdependence.  Opera- 
tions give  some  idea  of  these  ;  but  the  lesson  is  marred  by 
the  paralysing  effect  of  the  anaesthetic.  What  a  difference 
must  Life  make  to  our  idea  of  the  thorax  and  its  contents — 


2  DIAGNOSIS 

the  expansion  and  shrinking  of  the  lungs,  the  rising  and  falling 
of  the  diaphragm  and  of  the  ribs,  the  mighty  contractions 
of  the  heart  !  How  marvellous,  too,  must  appear  the  har- 
monious co-ordination  of  the  many  muscles  used  in  a  complex 
voluntary  act — some  slightly,  some  moderately,  and  some 
fully  contracted  !  What  a  contrast  there  must  be  between 
the  flabby  colon  of  the  post-mortem  room  and  the  same  organ 
shortened,  thickened,  and  stiffened  by  the  tonic  contraction 
of  its  muscular  bands.  It  is  this  power  of  visualising  that 
makes  the  brilliant  clinician. 

To  complete  the  equipment  of  the  ideal  diagnostician,  some- 
'  thing  resembling  legal  acumen  should  be  added,  by  the  aid 
of  which  the  statements  of  the  patient  and  those  of  his  friends 
may  be  so  sifted  that  only  the  truth  remains.  A  good  rule 
is  to  ask  no  leading  questions,  for  in  this  way  the  fallacy 
of  '  suggestion '  may  be  avoided  ;  but  with  stupid  people  it 
is  not  always  possible  to  avoid  framing  a  question  so  as  to 
get  '  yes  '  or  '  no  '  for  an  answer — at  least  not  without  much 
loss  of  time. 

2.  Classification  of  Patients.— Patients  in  this  connection 
may  be  classified  into  four  divisions  :  the  pessimistic,  the  opti- 
mistic, the  complaisant,  and  the  mendacious.  The  Pessi- 
mistic Patient  is  usually  either  hysterical  or  '  liverish.'  The 
former  will  speak  with  a  cheerful  countenance  of  agony  endured  ; 
the  latter,  like  Rachel,  refuses  to  be  comforted.  The  Optimist 
is  perhaps  still  more  misleading,  for  he  commonly  fails  to  mention 
more  than  half  his  complaints  and  passes  lightly  over  the  others  ; 
the  statements  of  such  patients  should  be  checked  by  the  results 
of  a  private  interview  with  the  nearest  relation.  The  Com- 
plaisant Patient  is  one  who,  instead  of  the  correct  answer, 
gives  that  which  he  imagines  is  in  the  mind  of  the  questioner. 
Is  it  a  libel  to  say  that  he  usually  hails  from  the  Emerald 
Isle  ?  The  Mendacious  Patient  is  found  chiefly  in  hospital 
practice.  Unlike  the  malingerer  and  the  fraudulent  claimant 
for  compensation,  he  is  not  wilfully  untruthful ;  but  by  dint 
of  exaggeration,  misrepresentation,  and  omission,  he  often  ends 
in  being  very  misleading.  Especially  to  be  mistrusted  in  his 
statements  of  the  views  and  diagnosis  of  the  previous  medical 
attendant.  This  should  always  be  listened  to  with  discreet 
silence.  These,  then,  are  some  of  the  Fallacies  of  Diagnosis; 
but  there  are  others  : — 

2 


FALLACIES  OF  DIAGNOSIS  3 

3.  The  Fallacy  of  Suggestion. — If  it  be  true  that  suggestion 
can  remove  pain,  it  is  no  less  true  that  it  is  capable  of  creating 
not  only  pain,  but  other  nervous  symptoms.  To  ask  a  neurotic 
patient  day  after  day  if  a  given  pain  or  spasm  have  extended 
to  another  part,  is  just  the  way  to  make  it  do  so. 

4.  The  Fallacy  of  Antecedent  Disease. — This  is  most  likely 
to  arise  in  a  case  of  coma,  or  when  the  patient  is  otherwise  un- 
able to  speak.  An  old  facial  paralysis  or  squint  in  the  subject 
of  alcoholic  coma  would  be  very  liable  to  lead  to  a  diagnosis 
of  apoplexy. 

5.  The  Fallacy  of  Concurrent  Disease. — An  instance  of 
this  may  be  found  when  a  chronic  disease  is  mistaken  for  an 
acute  one,  owing  to  its  association  with  simple  tonsillitis  or 
other  unimportant  condition  involving  a  rise  of  temperature. 
I  have  known  a  clear  case  of  gout  diagnosed  as  gonorrhceal 
rheumatism  because  a  urethral  discharge  was  present.  It  is  not 
to  be  expected  that  gonorrhoea  would  confer  immunity  from 
gout. 

6.  The  Fallacy  of  Obsession. — It  is  very  curious  to  notice 
that  when  a  practitioner's  mind  is  full  of  a  certain  disease — 
whether  by  a  recent  personal  experience,  a  striking  instance  of 
a  rare  disease  in  his  own  practice,  or  even  a  noticeable  discussion 
upon  a  given  disease  in  the  medical  papers — a  run  of  such  cases 
is  likely  to  follow  even  when  there  is  no  question  of  infection. 
Coincidence  might  account  for  a  second  case,  but  not  a  third 
or  a  fourth.  The  fact  is,  the  diagnosis  is  faulty,  and  the  fault 
is  due  to  obsession.  Appendicitis  is  very  much  in  our 
thoughts  just  now,  and  I  believe  many  abdominal  affections 
are  erroneously  diagnosed  as  such  by  reason  of  this  obsession. 
Again,  when  influenza  was  so  rife,  any  acute  disease  beginning 
with  pain  in  the  head  and  limbs  and  shivering  was  liable  to  be 
attributed  to  it,  much  to  the  after  discomfiture  of  the  physician 
when  the  nature  of  the  case  became  clear.  This  is  the  fallacy 
that  besets  the  specialist,  who  is  much  too  prone  to  find  only 
his  own  speciality  in  the  case  before  him.  The  point  is  of  all 
the  more  importance  because,  owing  to  the  unwieldiness  of 
Modern  Medicine,  the  time  is  rapidly  coming  when  almost 
every  doctor  will  be  a  specialist,  and  wide  knowledge  of  Medicine 
will  be  rarely  met  with.  The  consultant  will  then  be  a  sort  of 
glorified  general  practitioner,  who  will  collate  and  pronounce 
upon  the  findings  of  the  specialists. 

B  2  3-6 


4  FALLACIES  OF  DIAGNOSIS 

7.  The  Fallacy  of  Perspective. — This  is  of  two  kinds.  That 
of  the  old  general  practitioner  lies  in  the  assumption  that  his 
patient  is  the  subject  of  some  common  disorder  ;  that  of  the 
advanced  student  and  the  junior  consultant,  that  the  patient 
is  the  subject  of  a  rare  disease.  Hospitals  are  centres  for  rare 
diseases,  and  the  one  class  sees  too  few,  the  other  too  many  of 
them. 

8.  The  Fallacy  of  Variations  within  the  Normal. — A  whole 
book  might  be  written  on  this  subject.  Pathognomonic  symp- 
toms are  exceedingly  rare,  and  it  may  be  affirmed  as  a  general 
proposition,  that  any  variation  which  is  absolutely  unsupported 
by  other  evidence  pointing  to  disease  must  be  considered  either 
normal  or  accidental.  The  usual  formula  with  the  laity  is 
that  such  and  such  a  peculiarity  is  constitutional.  Many  indi- 
viduals go  through  life  with  a  slow  pulse,  a  furred  or  fissured 
tongue,  or  contracted  pupils,  and  are  none  the  worse  for  these 
variations,  while  others  show  hyaline  casts  or  present  some 
solitary  physical  sign  oi  no  significance. 

9.  The  Fallacy  of  the  Personal  Equation. — This  is  of  two 
kinds  :  that  of  the  physician  and  that  of  the  patient.  The 
latter  has  been  already  dealt  with  in  the  paragraph  on  the 
classification  of  patients.  The  temperament  of  the  doctor  is  apt 
to  affect  his  diagnosis.  While  the  cheery  optimist  refuses  to 
believe  until  perhaps  too  late  that  his  patient  is  the  subject  of 
a  grave  disease,  the  dismal  doctor  harrows  unnecessarily  the 
friends'  feeling  by  his  gloomy  fears.  Not  only  so,  but  even  the 
same  doctor,  bright  and  fresh  in  the  morning,  may  feel  none  of 
the  forebodings  which  hampered  his  judgment  when  tired  out 
and  hungry  overnight. 

10.  The  Fallacy  of  Transferred  Pain. — This  is  a  common 
source  of  error.  Where  it  depends  upon  well-known  physio- 
logical laws,  as  in  the  case  of  pain  in  the  knee  in  hip- joint 
disease,  the  difficulty  is  small ;  but  in  other  cases,  such  as  the 
pain  in  the  shoulder  which  occurs  in  disease  of  the  colon,  and 
still  more  when  the  pain  and  even  the  tenderness  are  referred  to 
the  opposite  side,  the  difficulty,  in  the  absence  of  objective 
symptoms,  may  be  insurmountable.     (Sse  153,  325.) 

11.  The  Fallacy  of  Malingering. — The  Malingerer  belongs 
chiefly  to  the  uneducated  classes,  and  the  master-key  to  his 
detection  lies  in  the  fact  that  he  is  unable  to  think  of  two  things 
at  the  name  time.     For  instance,  the  writer,  who  has  a  large 

7-11 


FALLACIES  OF  DIAGNOSIS  5 

experience  of  these  cases,  found  out  that  a  man  he  was  examining 
was  a  red-hot  politician,  and  mistrusting  the  cries  with  which 
he  rent  the  air  when  a  certain  part  of  his  back  was  lightly  touched, 
proceeded  to  vilify  the  man's  political  party.  Then,  taking 
advantage  of  his  excitement,  and  exclaiming,  '  Don't  excite 
yourself,'  he  emphasised  the  remark  with  a  sounding  slap  on  the 
same  spot.  The  man  took  no  notice  !  In  practice  it  will  often 
be  found  advantageous,  while  ostensibly  examining  one  organ, 
to  watch  furtively  another.  A  large  number  of  notes  bearing 
on  the  subject  will  be  found  scattered  through  this  work. 

11a.  Classification  of  Symptoms.— Hitherto,  the  only  suc- 
cessful classification  has  been  the  division  into  Subjective  and 
Objective  Symptoms.  This  is  admirable  as  far  as  it  goes,  but 
it  does  not  go  far  enough.  It  is  true  that  there  is  the  sub- 
class, Physical  Signs  ;  though  why  signs  elicited  by  the  ther- 
mometer and  sphygmometer,  which  have  at  least  an  equal  right 
to  the  title,  are  excluded  from  the  group  is  not  clear.  Classifica- 
tion according  to  the  organ  affected  is  also  illogical,  for  the 
symptom  cannot  be  classed  until  a  diagnosis  has  been  made  ; 
dyspnoea  for  instance  would  be  termed  a  lung  symptom  ;  but 
after  examination  it  might  easily  prove  to  be  a  blood  symptom 
or  a  heart  symptom.  Moreover,  one  organ  cannot  be  affected 
very  long  without  involving  others. 

Until  its  elements  have  been  duly  classified,  Semeiology  can 
have  no  claim  to  be  regarded  as  one  of  the  Sciences  ;  for  classifica- 
tion is  the  foundation  of  all.  The  system  here  set  forth  provides 
a  niche  for  every  symptom  known  or  unknown.  It  should  lead 
to  greater  precision  of  thought  and  by  exposing  the  gaps  in  our 
knowledge  it  should  direct  and  stimulate  further  investigation. 


ll-lia 


PtVRT  I 

INTERROGATION 

The  order  of  the  symptoms  is  approximately   that  adopted  ki 
case-taking.     The  regions  proceed  from  the  head  downwards. 

Notes  beginning  with  a  capital  letter  refer  to  the  section ; 
those  with  a  small  letter  to  the  preceding  disease. 

Contractions  :  u,  usually ;  x,  exceptionally ;  *,  tho  most  likely 
diseases.  I,  First  stage ;  n,  Second  stage ;  in,  Third  or  Final 
stage. 


PREDOMINANT    SEX 

Irrespective  of  structural  differences. 


12.  Male 


The  diseases  which  pre- 
ponderate in  the  male  are 
largely  those  due  to 
laborious  occupation,  to 
exposure  to  weather, 
or  to  alcoholism  or 
syphilis. 

Actinomycosis  -^ 
Addison's  Disease  -j- 
Amyotrophic  Lat.  Sclerosis 
Aneurysm,   Abdominal  ^ 

,,  in  general 

Angioneurotic  (Edeina 
Angina  Pectoris 
Aortitis 
Appendicitis  |- 
Ascending         Paralysis, 

Acute  -£ 
Bilharzia 
Bulbar  Paralysis 


Cancer  of  Kidney 

,,       of  Rectum 

,,       of  Stomach  \ 
Cerebral  Abscess 
Chloroma  Ap 
Cirrhosis  of  Kidney  -| 

,,  of  Liver  |- 

,,  of  Stomach 

Claudication  Intermittente 
Colour-blindness 
Cystic  Kidney  \ 
Cystinuria 
Diabetes  \ 

except  the  hereditary  form 

Diabetes  Insipidus  \ 
Duodenal  Ulcer  \ 
Dupuytren's     Contrac- 
tion  -2j& 
Endocarditus,  Ulcerative  \ 
Enteric  Fever 

12 


SEX 


Male — continued 

Epilepsy 

Exophthalmic  Goitre 
senile  form 

Exostosis 

Fatty     Degeneration      of 
Heart  y 

Gastritis,  Chronic 

Gilles    de    la    Tourette's 
Disease 

Gout 

Gumma  y 

Hematoma  Auris 

Hemoglobinuria,       Inter- 
mittent 

Haemophilia  -y1- 

Haemorrhage  into  Cord 

Hypertrophy  of  Heart 

Hypochondriasis 

Idiopathic      Dilatation      of 
the   Colon — infants   y 

Intussusception 

Laryngeal  Affections 

Leukaemia  y 

Locomotor  Ataxy  y 

Lymphadenoma  y 

Meningitis,  Cerebro-  spinal 
,,  Simplex  \ 

„  Spinal 

Myocarditis 

Myositis  Ossificans 

Pachymeningitis 

Pancreatitis 

Paralysis  agitans 

Paraplegia,  Ataxic 

Peliosis  rheumatica 

Pneumonia 

Progressive  Muscular  Atro- 
phy, f 

Pseudo-hypertrophic    Para- 
lysis 


Pylorus,  Congenital  Hyper- 
trophy of  -£ 
Rheumatism,  Acute  ^ 
Sciatica 

Schlatter's  Disease 
Serratus  Magnus  Palsy   \ 
Spasmodic  Spinal  Paralysis 
Stokes-Adams'  Disease. 
Syringomyelia  y 
Thomsen's  Disease 
Tooth's  Paralysis 
Valvular  Disease 
Weil's  Disease 

13.  Female 

The  diseases  to  which  female 
are  specially  subject  are 
those  that  arise  from 
indoor  life  and  insufficient 
exercise. 

Acroparaesthesia  -T° 
Adiposis  Dolorosa 
Anaemia 

Arthritis,  Intermittent 
Atrophy,  Acute  Yellow 
especially  during  pregnancy 

Atrophy  of  Heart  | 

Catalepsy 

Chlorosis 

Chorea  T 

Cceliac  Disease 

Constipation 

Dementia,  Ac.  Primary 

Disseminated  Sclerosis 

Enteroptosis  -y^- 

Erythema  nodosum 

Facial  Hemiatrophy 

Floating  Kidney  | 

Gall  Bladder,  Cancer  of  Y 

Gallstones  | 

Gastralgia 

12-13 


SEX 


Female — continued 

Gastric  Ulcer 
Goitre 

„     Exophthalmic  ^ 
Hysteria 
Idiopathic    Dilatation 

Colon — Adults  \ 
Korsakoff's  Syndrome 
Lupus  Erythematosus 
Manus  Valga 
Membranous  Colitis 
Mitral  Stenosis  \ 
Mollities  Ossium  -^ 
My x oedema  -| 
Neuralgia 
Piedra 


of 


Pharyngomycosis 
Proctitis,  Ha3morrhagic 
Pscudangina 
Pulsating  Aorta 
Pyelitis,  Infantile  j- 
Raynaud's  Disease 
Rheumatoid  Arthritis 
Rhinitis,  Chr.  Atroph. 
Scleroderma 
Stricture  of  Rectum 
Trance 
Trypanosomiasis 

European  clothes  ±£ 
Tuberculous  Peritonitis  % 


13 


10  AGE 

AGE 

Diseases  prone  to  occur  at  certain  ages. 

14.  In  the  absence  of  direct  information,  it  may  be  necessary 
to  form  an  estimate  of  the  patient's  age  ;  but,  since  illness  is 
sure  to  add  to  this  in  appearance,  it  is  not  always  an  easy  matter. 
The  best  guide,  perhaps,  is  the  texture  of  the  skin,  which  becomes 
more  and  more  inelastic  and,  later,  more  and  more  leathery,  as 
age  advances.  Wrinkles  are  a  guide  to  some  extent ;  but  they 
develop  prematurely  in  those  much  given  to  laughter  or  gesticula- 
tion. In  women  the  advent  of  the  menopause  is  often  indicated 
by  the  growth  of  hair  on  the  chin  and  upper  lip  ;  and,  in  both 
sexes,  middle  age  may  be  betrayed  by  a  certain  stiffness  at 
the  hip  joints  in  walking.  Grey  hairs  usually  begin  to  appear 
about  the  fortieth  year,  but  they  are  not  very  marked  for 
ten  or  twelve  years  after  that ;  premature  greyness,  however,  is 
common  enough,  and  is  then  usually  hereditary.  The  tortuous 
temporal  artery  and  the  arcus  senilis  are  not  necessarily  confined 
to  old  age  ;  indeed,  thanks  to  the  very  general  use  of  artificial 
teeth,  the  classical  signs  of  old  age  are  rarely  seen  except  amongst 
the  very  poor. 

15.  The  Examination  of  Children  presents  many  difficulties. 
The  first  thing  to  do  is  to  endeavour  to  get  the  child's  confidence. 
For  this  purpose  the  practitioner  must  give  him  time  to  get  used 
to  his  presence  by  getting  all  the  information  possible  from  the 
nurse  or  mother.  He  may  then  ask  the  child  to  shake  hands, 
and  can  surreptitiously  feel  the  pulse  at  the  same  time,  or  perhaps 
get  the  mother  to  hold  the  child's  hand  while  he  does  so.  If  the 
suspicious  patient  will  not  put  out  his  tongue,  he  will  probably 
open  his  mouth  wheri  asked  and  this  will  do  nearly  as  well,  and 
the  opportunity  may  then  be  taken  to  pass  the  finger  rapidly 
over  the  gums.  The  chest  should  next  be  listened  to,  and  if  a 
single  stethoscope  is  employed,  the  child  should  previously 
have  been  allowed  to  examine  it  under  the  specious  name  of 
trumpet.     Percussion  is  apt  to  make  a  child  cry  ;    it  should 

-therefore  follow,  not  precede,  auscultation,  and  as  a  rule, 
one  finger  only  is  necessary  to  form  the  plessor.  The  throat 
may  be  examined  by  using  the  handle  of  a  teaspoon  as  a  tongue- 
depressor  ;  the  examination  nearly  always  sets  the  child  crying, 
but  this  is  of  less  importance  now,  as  the  ordeal  is  nearly  over, 

14-15 


AGE 


11 


and  the   cry  affords  an  opportunity  to   determine   the   vocal 
fremitus  and  resonance. 

The  symptoms  of  disease  present  certain  modifications  when 
affecting  children.  Thus,  the  pain  of  lobar  pneumonia  is  often 
referred  to  the  epigastrium,  and  the  disease  itself  may  affect  the 
apex  instead  of  the  base.  The  rigor  of  onset  is  often  replaced 
by  convulsions.  Vomiting  is  exceptionally  common  in  children, 
perhaps  from  the  more  vertical  position  of  the  stomach,  and  this 
and  diarrhoea  are  remarkable  for  the  rapid  wasting  by  which  they 
are  followed.  The  whoop  of  pertussis  is  often  absent  in  young 
infants,  and  in  all  children  it  usually  disappears  temporarily 
during  an  attack  of  measles.  Other  peculiarities  will  be  found 
noted  in  the  interlineations  of  the  text. 

In  the  following  lists,  where  the  disease  occurs  in  more 
than  one  age  section,  the  numbers  of  the  others  are  given. 
In  incurable  diseases,  only  the  age  of  onset  is  usually  inserted. 


16.  Infancy  (under  2  years) 
Amaurotic  Family  Idiocy 
Amyloid  Degeneration  (17) 
Bronchitis  (17,  22) 
Broncho-pneumonia  (17) 
Convulsions  (17) 
Cretinism  (17) 
Diarrhoea 

Diphtheria,  Laryngeal  (17) 
Erythema  Infectiosum  (17) 
Glands,  Enlarged  (17,  18) 
Glandular  Fever  (17) 
Hereditary  Muscular    Atro- 
phy 
Hooping  Cough  (17) 
Hydrocephalus  (17) 

,,  Spurious 

Idiopathic  Dilatation  of  the 

Colon 
Impetigo  contagiosa  (17) 
Infantile  Hemiplegia 
Scurvy  (17) 

begins  at  6  to  10  m. 


Intertrigo 
Intussusception  (17) 

720/o  under  one  year 

Laryngismus   stridulus   (17) 
Laryngitis,  Spasmodic  (17) 
Lichen 
Manus  Valga 
Measles  (17,  18) 
Meningitis,  Tuberculous  (17) 
Meningitis,  Post  Basic 

u  under  9  months 

Paralysis,  Infantile  (17) 
Ponos  (17) 
Post-pharyngeal        Abscess 

(17) 
Purpura,  Henoch's 
Pyelitis 
Rickets  (17) 
Rotheln  (17,  18,  19) 
Scarlatina  (17,  18) 
Seborrhoea  (18) 
Spasmus  nutans 

15-16 


12 


AGE 


In  fan  c y — continu  ed 
Syphilis,  Hereditary 

it  appears  at  2  to  G  weeks 

Syphilitic  Disease  of  Lungs 
(17) 
,,  Epiphysitis 

,,  Pemphigus  (17) 

Tetany  (17) 
VariceUa  (17) 

Werdnig-Hofmann  Atrophy 
(17) 

17.  Childhood 

Addison's  Disease  (x)  (18,20) 

Adenoids 

Amyloid  Degeneration   (16) 

Banti's  Disease 

Bronchitis  (16,  22) 

Broncho-pneumonia  (16) 

Cataract,  Soft 

Cerebro- spinal  Meningitis 

Chloroma  (18) 

Chondroma  (18) 

Chorea  (18) 

Cirrhosis,  Hypertrophic  Bili- 
ary (x) 

Coeliac  Disease 
begins  about  2 

Convulsions  (16) 

Coxa  vara 

about  3  and  again  at  14 

Cretinism 

Diphtheria  (16,  18) 
Encephaloid  Cancer 
Endocarditis  (18,  19,  20) 
Enteric  Fever  (18) 
Epilepsy  (18) 

Erythema  Infectiosum  (16) 
Exophthalmic  Goitre  (x) 
Facial  Hemiatrophy 


Floating  Kidney  (x) 
Friedreich's  Disease  (18) 
Gilles     de     la     Tourette's 

Disease 

Glands,  Enlarged  (16,  18) 

Glandular  Fever  (16) 
'  Growth  Fever ' 
Haemophilia 

Hooping  Cough  (16) 
Hydrocephalus 
Impetigo  contagiosa 
Infantile  Scurvy  (16) 
Intussusception  (16) 
Laryngismus  stridulus  (16) 
Laryngitis,  Spasmodic  (16) 
Little's  Disease 
under  5 

Lumbrici 
Measles  (16,  18) 
Meningitis,  Tuberculous  (16) 
Mumps  (16,  18) 
Myeloma  (18) 
Myoclonus  Multiplex 
Noma 

(Edema  laryngis  (18) 
Paralysis,  Infantile  (16) 

tj  under  5 

Paramyotonia  Congenita 
Paroxysmal  Tachycardia  (x) 
Peritonitis,  Tuberculous 
Ponos  (16)  f 
Post-pharyngeal        Abscess 

(u  under  4) 
Pseudo-hypertrophic    Para- 
lysis 
Purpura,  Henoch's 
Rheumatic  Nodules 
Rheumatism  (18,  19,  20) 

rare  under  3 
Rhinitis,  Atrophic  (18) 
16-17 


AGE 


13 


Childhood — continued 
Rickets  (16) 
Ringworm 
Roseola 

Rotheln  (16,  18,  19) 
Sarcoma,  Renal 
Scarlatina  (16,  18) 
Schlatter's  Disease  (18) 
Scurvy,  Infantile  (16) 
Spinal  Paralysis,  Epidemic 
Status  Lymphaticus 
Syphilis,  Hereditary  (16) 
Syphilitic  Lungs  (16) 

,,  Pemphigus  (16) 

Tetany  (16) 
Thomsen's  Disease 

4  to  6 
Threadworms  (16) 
Tubercle  of  Bones,  etc. 
Tuberculous    Tumours    of 

Brain 
Varicella  (16) 
Werdnig-Hofmann  Atrophy 

(16) 


18.  Adolescence 

Acne 

Addison's  Disease  (20) 

Amenda  (19) 

Apoplexy,  Spinal 

Appendicitis  (19) 

Catalepsy 

Cerebellar  Ataxy 

Cerebral      Embolism      (19. 

20) 
Chloroma  (17) 
Chlorosis 
Chondroma 
Chorea  (17) 
Coxa  vara  (17) 


Dementia,  Ac.  Primary 
Diabetes  Insipidus 
Diphtheria  (16,  17) 
Endocarditis  (19,  20) 
Enteric  Fever  (17) 
Epilepsy  (17) 
Exophthalmic     Goitre     (x), 

(20,  21,  22) 
Exostosis 

Friedreich's  Disease  (17) 
Glands,  Enlarged  (16,  17) 
Goitre  (21) 
Hysteria  (21) 
Measles  (16,  17) 
Meningitis,  Simple 
Migraine 
Mitral  Stenosis 
MoUities  Ossium  (20) 
Mumps  (16,  17) 
Myeloma  (17) 
Myocarditis 
Myomata  (19,  20) 
Myxcedema  (20) 
Nervous  Atrophy 
CEdema  laryngis  (17) 
Periodic  Paralysis  (19) 
Pharyngomycosis  (19) 
Phthisis  (19) 
Progressive  Muscular  Atro- 

phy  (x)  (19,  20) 
Rhachitis  adolescentium 
Rheumatism,  Acute  (17,  19, 

20) 
Rhinitis,  Atrophic  (17) 
Rotheln  (16,  17,  19) 
Sacro-iliac  Disease 
Scarlatina  (16,  17) 
Schlatter's  Disease  (17) 
Seborrhcea  (16,  20) 
Spasmodic  Spinal  Paralysis 
Syringomyelia  (19,  20) 

onset 

17-18 


14 


AGE 


Adolescence — continued 
Trance 

Tuberculosis,  Acute  (19,  20) 
Ulcer  of  Stomach  (19,  20) 
Vincent's  Angina  (19) 


19.  Young  Adults 

Actinomycosis 

Anaemia  (18) 

Appendicitis  (18,  20) 

Cerebral  Abscess  (20) 

Cerebral  Embolism  (18,  20) 

Dementia  Precox  (20) 

Disseminated  Sclerosis  (20) 

Duodenal  Ulcer 

Endocarditis  (  17,  18,  20) 

Gastralgia 

Hemorrhage  into  Cord  (20) 

Myomata  (20) 

Paralysis,     Ac.     Ascending 

(20) 
Peliosis  rheumatica 
Periodic  Paralysis  (18) 
Pharyngomycosis  (18) 
Phthisis  (18) 

Poliomyelitis,  Ac.   Ant.    (x) 
Primary  Spastic  Paraplegia 

(20) 
Proctitis,  Hemorrhagic 
Progressive  Muscular  Atro- 
phy (18,  20) 
Rheumatism,  Acute  (18,  20) 
Rheumatoid    Arthritis    (20, 

21) 
Rotheln  (16,  17,  18) 
Seborrhcea  Capitis 
Serratus  Magnus  Palsy  (20) 
Symmetrical  Adeno-lipoma- 

tosis  (20) 
Syringomyelia  (18,  20) 


Tuberculosis,  Acute  (18) 
Ulcer  of  Bladder 

„     of  Stomach  (18,  20) 
Vincent's  Angina  (18) 
Yellow  Atrophy,  Acute  (x) 

(20) 


20.  Middle  Age 

Addison's  Disease  (18) 

Aneurysm  (22) 

Angina  Pectoris  (22) 

Apoplexy 

Cancer  of  Stomach,   Liver, 

Larynx,  Rectum,  Uterus, 

or  Breast 
Cerebral  Abscess  (19) 

Embolism   (18,  19) 
(u  under  50) 
Cirrhosis  of  Liver  or  Kidney 
Claudication  Intermittente, 

(22) 
Cystic  Kidney 
Diabetes 

Dissecting  Aneurysm 
Dupuytren's  Contraction 
Endocarditis  (17,  18,  19) 
Epithelioma  (22) 
Exophthalmic    Goitre    (18, 

21,  22) 
Fatty  Degeneration  of  Heart 

(22) 
Gallstones 
Gout  (21,  22) 

Hemorrhage  into  Cord  (19) 
Hypochondriasis 
Idiopathic    Dilatation    of 

Colon  (x) 
Kidney,  Movable 
Korsakoff's  Syndrome 
Leukemia 

18-20 


AGE 


15 


Middle  Age — continued 

Locomotor  Ataxy 

Melancholia, 

Mollities  Ossium  (18) 

Myelitis 

Myomata  (18,  19) 

Myx oedema  (18) 

Nephritis,  Chronic 

Neuralgia,  Trigeminal 

Osteitis  Deformans 

Osteo-arthritis.  22 

Paralysis,    Ac.    Ascending 
(19) 
,,  agitans  (22) 

,,  Bulbar 

„  General 

Paraplegia,  Ataxic 

Pernicious  Anaemia 

Primary  Spastic  Paraplegia 
(19) 

Progressive  Muscular  Atro- 
phy (u  25-45) 

Rheumatism,  Acute  (18,  19) 

Sciatica  (22) 

Sclerosis,  Disseminated  (19) 

Serratus  Magnus  Palsy  (19) 

Spinal    Meningeal    Haemor- 
rhage 

Stricture  of  Rectum 

Symmetrical  Adeno -lipoma- 
tosis (19) 

Syringomyelia  (18,  19) 

Thrombosis  (22) 

Tumours,  Intracranial 

except  tuberculous 

Ulcer  of  Stomach  (18,  19) 

,,      of  Colon 

,,      of  Duodenum 
Weil's  Disease 
Yellow      Atrophy,      Acute 

(19) 


21.  Menopause 
Cancer 

Caruncle,  Urethral 
Diabetes 

Exophthalmic  Goitre 
Goitre 
Gout 
Hysteria 
Insanity 
Pruritus  Vulvaj 
Pseudangina 
Rheumatoid  Arthritis 
Uterus,  Prolapse  of 


22.  Old  Age 

Aneurysm  (20) 
Angina  Pectoris  (20) 
Aortitis 
Apoplexy 

u  over  50 
Arterio-sclerosis 
Brachial  Neuritis 
Bronchitis  (16,  17) 
Cancer 

Capillary  Bronchitis 
Cataract 

Cerebral  Thrombosis 
Chorea,  Senile 
Claudication    Intermittente 

(20) 
Diarrhoea 

Dissecting  Aneurysm 
Ecthyma 
Epithelioma  (20) 
Exophthalmic  Goitre 
in  men 

Fatty  Degeneration  of  Heart 

(20) 
Gangrene 
Gout  (20,  21) 

20-22 


1G 


AGE 


Old  Age — continued 
Melancholia 
Osteoarthritis 
Pachymeningitis 
over  50 

Paralysis  agitans  (20) 
Pemphigus 


Phthiriasis 
Prostatic  Disease 
Pruri  bus 
Sciatica  (20) 
Thrombosis  (20) 
Ulcer,  Rodent 


23.  Congenital  Affections 

The  following  diseases  are,  at  least  sometimes,  congenital. 


Achondroplasia 

Amblyopia 

Amyotonia  Congenita 

Angeiomata 

Aphasia 

Atelectasis 

Buhl's  Disease 

Cataract 

Cholsemia,  Congenital 

Chorea  (x) 

Corneal  opacities 

Deaf-Mutism 

Dermatitis  Exfoliativa 

Development,  Ai rested 

Dislocations  of  Hip,  etc. 

Facial  Hemiatrophy 

Haemophilia 

Heart  Affections 

Hernia 

Hydrocephalus 

Hydronephrosis 

Ichthyosis 

Icterus  neonatorum 

Idiocy 


Idiopathic  Dilatation  of  the 
Colon 

Infantile  Hemiplegia  4- 
,,        Hemoglobinuria 

Malformations 

Manus  Valga 

Multiple  Osteomata 

Naevi 

Paralysis  of  Sixth  Nerve 

Paramyotonia  Congenita 

Paraplegia,  Spastic 

Pemphigus 

Progressive  Muscular  Atro- 
phy 

Pseudo-hypertrophic     Para- 
lysis 

Ptosis 

Pylorus,  Hypertrophy  of 

Sclerema 

Spastic  Cerebral  Paraplegia 

Syphilis 

Syringomyelia 

Tetanus  neonatorum 

Thomsen's  Disease 

Word- Blindness,  Cong. 


22-23 


OCCUPATION 


17 


OCCUPATION 

It  may  be  necessary  to  know  the  past  as  well  as  tho 
present  occupation. 


24.  Active 

Bichromate   Workers  : 

Aneurysm 

Ulcers,  Erosion   of   Nasal 

Dislocations 

Septum 

Fractures 

Accumulator 

Heart,  Hypertrophy  of 

Makers 

Hernia 

Painters 

Rheumatic  Fever 

Dyers 

Rupture  of  Valve  Cusp 

Enamellers 

Lead- 

Sprains 

Potters 

\  poisoning, 
Gout 

Tetanus 

Glass 

Polishers 

25.  Sedentary 

Plumbers 

Anaemia 

White- Lead 

Arterio- sclerosis 

Makers 

Chlorosis 

Bark   Strippers :     Keratosis 

Constipation 

Buttle  Makers  :    Cataract 

Dyspepsia 

Compositors  :  Nystagmus 

Fatty  Heart 

Cooks  :  Eczema,  Erythema 

Gallstones 

India-rubber  Workers : 

Gastritis 

Amaurosis,        Temporary 

Gout 

Hysteria  and  Mania,  Peri- 

Haemorrhoids 

pheral    Neuritis,    Derma- 

Hysteria 

titis 

Hypochondriasis 

Pitch,    Workers  in :    Warts 

Neuroses 

(becoming       epithelioma- 

Obesity 

tous)    Ulceration     of 

Phthisis 

Cornea 

Ulcer  of  Stomach 

Dusty  Trades  :    Cirrhosis  of 

Lungs,     Chronic     Laryn- 

26. Trade  Diseases 

gitis 

Brass    Founders :     Pseudo- 

Brickmakers :       Ankylosto- 

Ague 

miasis 

Boiler  Makers  :  Deafness 

Miners :      Phthisis,     Anky- 

Bakers 

lostomiasis,      Nystagmus, 

Grocers 

■  Dermatitis 

'  Beat-knee  '  or  '  -elbow,' 

Bricklayers 

Epithelioma 

,  (Scrotal) 

24-26 


18 


OCCUPATION 


) 


Anthrax 


Trade  Diseases — continued 
Domestic    Servants :     Anae- 
mia, Gastric  Ulcer,  Ery- 
thema nodosum,  Varicose 
Veins 
Butchers :     Weil's     Disease 
Skin  Dressers 
Wool  Sorters 
Sweeps :      Epithelioma     of 

Scrotum 
Gold-beaters  )    Side- 

Olass  Polishers     j        rosis 
Furriers :       Arsenic-poison- 
ing, Mercurialism 
Felt-hat  Makers  :  Mercurial- 
ism 
Gardeners :    Tetanus 
Corn     Trades  :     Actinomy- 
cosis,   Aspergillosis,  Ger- 
lier's  Disease 
Bird  Fanciers  ;    Psittacosis, 

Aspergillosis 
Stokers  :   Apoplexy 
Divers  :    Caisson  Disease 
Match     Makers :  Phos- 

phorus-poisoning 
Electric-light  Workers :  Con- 
junctivitis 


X-Ray     Workers :     Derma- 
titis, Impotence 
Sailors  :  Exostosis  of  Ear 
Standing  Occupations  :  Vari- 
cose Veins,  Flat  Foot 


27.  Occupation  Neuroses 

Writer's  Cramp  : 

Clerks 
Laryngeal  Spasm  : 

Cornet  Players 

Elocutionists 

Flautists 
Clonic  and  Tonic  Spasms 

Ballet  Dancers 

Compositors 

Hammermen 

Pianists 

Telegraphists 

Violinists 

Typists 

Tailors 

Sempstresses 

Shoemakers 

Cigarette  Rollers 

Milkers 


26-27 


HISTORY 


19 


28.    HISTORY 


Etiology  is  perhaps  the  least  reliable  of  all  our  aids  to 
diagnosis,  for  it  bristles  with  fallacies  and  notably  with  the 
post  hoc,  ergo  propter  hoc  variety. 

A  good  deal  of  care  therefore  is  necessary  to  obtain  accurate 
results,  especially  with  uneducated  people.  A  '  cold,'  given 
as  the  cause  of  death,  may  be  ascertained  by  questions  as 
to  duration,  wasting,  cough,  or  haemoptysis  to  have  been  in 
reality  phthisis.  '  A  complication  of  diseases '  will  generally 
be  found  to  include  dropsy  ;  and  a  few  appropriate  questions 
will  usually  elicit  such  information  as  will  determine  whether 
this  was  renal,  cardiac,  hepatic,  pulmonary,  or  heemic.  A  state- 
ment of  the  causes  of  the  deaths  in  the  family  is,  however, 
not  sufficient.  Inquiry  must  be  made  as  to  whether  any  living 
member  of  the  family  is  suffering  from  hereditary  disease,  and 
cross -heredity  must  be  borne  in  mind.  The  subject  is  of 
special  importance  in  examination  for  life  insurance.  According 
to  Galton's  Law,  each  parent  contributes  one-quarter  of  the 
inherited  faculties  and  each  grandparent  one-sixteenth. 


29.  Hereditary  Diseases 

Some  of  these  may,  like 
Tuberculosis,  prove  to 
be  infectious  with  a 
prolonged  latent  stage. 


Acne 

Adiposis  Dolorosa 

Angeioneurotic   (Edenia 

Apoplexy 

Arterio-sclerosis 

Asthma,  Hay  (x) 

„        Spasmodic  -l^ 
Cancer 
Calculus 

Colour- Blindness,  Cong. 
Cystinuria 
Dementia  Precox 
Diabetes  20% 

„         Insipidus 


(x) 


c  2 


Disseminated  Sclerosis 

Dupuytren's  Contraction 

Eczema 

Emphysema 

Epilepsy  -i- 

Facial  Hemiatrophy  (x) 

Fragilitas  Ossium 

Friedreich's  Disease 

Gout 

Haemophilia 

Heart  Disease 

Hereditary       Cerebellar 

Ataxy 
Hernia 

right  side  if  paternal 

Huntington's  Chorea 
Hysteria 
Hydrocephalus 
Hpyochondriasis 

28-29 


20 


HISTORY 


Hereditary    Diseases — con- 
tinued 

Ichthyosis 
Insanity  f 

Landouzy-Dejerine    Para- 
lysis 
Laryngismus  stridulus 
Leprosy  (?) 
Malformations 
Migraine 
Milroy's  Disease 
Myositis  Ossificans 
Nsevus 
Nephritis  (x) 
Neurasthenia 
Neuroses 
Nystagmus  (x) 
Obesity 

(Edema,  Circumscribed 
Otosclerosis 

Paramyoclonus  Multiplex 
Periodic  Paralysis 
Phthisis 

Primary  Spastic  Paraplegia 
Progressive  Muscular  Atro- 
phy (x) 
Pseudo-hypertrophic    Para- 
lysis 
Psoriasis  (x) 
Retinitis  Pigmentosa 
Rheumatic  Fever 
Rheumatism 
Rheumatoid     Arthritis,     or 

Joint  Trouble 
Senility,  Early 
Spondylose  Rhizomelique 
Syphilis 
Telangiectasis 
Tetany 

Thomsen's  Disease 
Tooth's  Paralysis 


Tuberculosis 
Tumours 

In  many  cases,  what  is 
really  inherited  is  a  dimin- 
ished power  of  resistance 
to  a  given  disease  and  not 
the  disease  itself. 

30.  Cross  Heredity 

Epilepsy —    \ 

Insanity         and  vice 
Epilepsy —    j    versa 

Migraine    ) 
Ac.   Rheumatism — Valvular 

Disease 

31.  Familial  Diseases 
Amaurotic  Family  Idiocy 
Congenital  Chohemia 
Cretinism 

Diabetes  (x) 

Disseminated    Sclerosis    (x) 

Fibroids,  Uterine 

Friedreich's  Disease 

Hereditary    Cerebellar    At- 
axia 
„        Muscular     Atro- 
phy 

Ichthyosis 

Landouzy-Dejerine   Para- 
lysis 

Lateral  Sclerosis 
family  type 

Myoclonus  Epilepticus 

Pentosuria 

Periodic  Paralysis 

Pseudo-hypertrophic    Para- 
lysis 
boys  of  same  family 

Retinitis  Pigmentosa 
Spastic  Paraplegia 

29-31 


HISTORY 


21 


Familial    Diseases  —  contd. 
Splenic    Anaemia, 

Gaucher  type 
Telangiectasis 
Thomsen's  Disease 
Word- Blindness,  Cong. 
Xeroderma  Pigmentosum 

32.  Previous  Attack  Favours  a 
Diagnosis  of 

Ague 

Angina  Pectoris 

Appendicitis 

Apoplexy 

Asthma,  Hay 

,,        Spasmodic 
Bronchitis 
Delirium  Tremens 
Epilepsy 
Erysipelas 
Gallstones 
Gout 

Hemoglobinuria,    Intermit- 
Lead-poisoning  [tent 

Migraine 
Neuralgia 
Osteomyelitis 
Quinsy 
Renal  Colic 
Rheumatic  Fever 
Rheumatism 
Tonsillitis 

33.  Previous  Attack  Precludes 

There  are  many  exceptions, 
however,  since  immunity 
following  an  attack  of 
infectious  disease  is  not 
necessarily  life-long. 

Enteric  Fever 
Hooping  Cough 
Measles 


Mumps 
Rotheln 
Scarlatina 
Syphilis 

cong.  or  acquired 
Typhus 
Varicella 
Variola 
Yellow  Fever 

*  Diphtheria  confers  little 
if  any  immunity.  Herpes 
Zoster  seems  to  have  some 
causal  connection  with 
Varicella. 

34.  HISTORY    OF    FORMER 
ILLNESS 

Gonorrhoea 

Gleet 

Iritis 

Ophthalmia 

Orchitis 

Pyaemia 

Rheumatism 

Stricture 

and  in  women,  peritonitis 
and  salpingitis. 

Gout 

Arterio- sclerosis 

Cerebral  Haemorrhage 

Cirrhosis  of  Kidney 

Eczema 

Neuritis 

Phlebitis 

Lead-poisoning 

Cerebral  Haemorrhage 

Cirrhosis  of  Kidney 

Fibroid  Heart 

Gout 

Multiple  Neuritis 

31-34 


22 


HISTORY 


History  of  Former  Illness 

— continued 
Rheumatic  Fever 

Chorea 
Embolism 
Endocarditis 
Exophthalmic  Goitre 

10  per  cent. 
Paramyotonia  Congenita 
Valvular  Disease 

Scarlatina 

Angina  Ludovici 

Nephritis 

Otorrhcea 

Rheumatism 

Tonsillitis 

Valvular  Disease 

Syphilis 

Aneurysm 

Cord,  Sclerosis  of 

Diabetes 

Eruptions 

General  Paralysis 

Gummata 

liver,  brain,  scalp,  etc. 
Heart,  Fibroid 
Iritis 

Locomotor  Ataxy 
Meningitis 

Pachymeningitis,  Cervical 
Periostitis 
Phthisis 

Thrombosis  of  Brain 
Tumour  of  Brain 

35.  History  of  a  Bite 

By  a  dog — rarely  a   cat  or 
a  fox. 

Hydrophobia 
Lyssaphobia 
Pyaemia 
Tetanus 


36.  History  of  Blow  or  Fall 

Abscess 
Arthritis 
Cancer 

Caries  of  Spine 
Concussion  of  Brain 
Dislocations 
Displaced  Cartilage 
Epilepsy 
esp.  Jacksonian 

Fibrositis 
Fractures 
Haemorrhages 
Meningitis 
Movable  Kidney 

„        Liver 
Myositis  Ossificans 
Neurasthenia,  Traumatic 
Pachymeningitis 
Pleurisy 
Prolapsus  Uteri 
Ruptured  Muscle 
„  Viscus 

Shock 

Spondylitis,  Traumatic 
Sprains 
Synovitis 
Tetanus 
Tuberculous  Arthritis 

with  a  free  interval 
Uterine  Displacement 
Vein,  Ruptured 

One-fifth  of  all  cases  of 
hysteria  are  of  traumatic 
origin  (Berbez). 

37.  History  of  a  Strain 

Aneurysm 
Apoplexy 
Fibrositis 
Haemorrhage 
Heart  Disease 

34-37 


HISTORY 


23 


History  of  Strain — continued 
Hernia 

Prolapsus  Ani 
,,        Uteri 

38.  History  of  Dietetic  Error 

Beri-Beri 

unpolished  rice 

Botulism 
infected  sausage,  etc. 

Diarrhoea 
rich  or  tainted  food 

Dyspepsia,  Acute 

pork,  crustaceans,  etc. 

Ergotism 

fungous  rye 
Hydatids 

raw,  unwashed  vegetables 
Lathyrism 

meal  made  from  Lathyrus 
Pellagra 

maize,  etc. 
Ptomainism 

decayed  food  (B.  Coli,  etc.) 
Trichinosis 

infected  raw  ham 
Urticaria 

shell  fish,  pork,  rabbit,  etc. 

Numerous  diseases  are  due 
to  infected  milk  or  water. 


39.  History  of  Alcoholism 

Aneurysm 

Apoplexy 

Arterio- sclerosis 

Atheroma 
*Cirrhosis  of  Liver 
♦Delirium  Tremens 

Dementia,  Chronic 

Dilatation  of  Stomach 

Emphysema,  Atrophic 

Gastritis,  Chronic 

Glycosuria 
*Gout 

Heart,  Dilated 
„      Fatty 
„      Fibroid 

Kidney,  Cirrhosis  of 
„        Enlarged 

Korsakoff's  Syndrome 
*Neuritis,  Multiple 

Pachymeningitis 

Pharyngitis,  Chronic 

Pneumonia 

Tuberculosis 

History  of  Rigor 

(see  236) 

History   of   Exposure   to  Con- 
tagion or  Infection 

See  Propagation  (44,  45) 

History  of  Residence  Abroad 

See  Exotic  Diseases,  1810 


37-39 


24 


ONSET 


ONSET 


40.  Sudden  Onset 

Acute  diseases  in  general. 
All  forms  of  lisemoirhago 
and  embolism. 

Ague 

Angina  Pectoris 

Ascending  Paralysis,  Acute 

Asthma 

Apoplexy,  Cerebral 

some  minutes 
Apoplexy,  Pulmonary 

,,  Spinal 

Appendicitis 
Caisson  Disease 
Catalepsy 
Cholera 
Colic,  Hepatic 

,,      Renal 
Dengue 
Embolism,  Cerebral 

instantaneous 
Embolism,  Renal 
Epileptic  Fit 
Erysipelas 
Facial  Paralysis 

unless  due  to  a  tumour 
Glandular  Fever 
Gout 

Hematocele,  Pelvic 
Hemorrhage,   Spinal  Inter- 

meningeal 
Hydrarthrosis,  Intermittent 
Infantile  Paralysis 
Influenza 

Jaundice,  Obstructive 
Korsakoff's  Syndrome 
Laryngismus  stridulus 
Mania 
Meniere's  Disease 


Meningitis,  Cerobro-spinal 
„  Internal  Spinal 

„  Post-Basic  (u) 

Myelitis 
Neuralgia 
Pancreatitis,  Acute 
Paralysis,  Acute  Bulbar 

,,  Acute  Spinal 

,,         Periodic 
Periarteritis  Nodosa 
Peritonitis,  Acute 
Pleurisy,  Acute 
Pneumonia,  Lobar 
Pyaemia 
Pyelitis,  Acute 
Rheumatic  Fever 
Syncope 

Thrombosis,  Cerebral 
some  hours 

Trance 

Tuberculosis,  Acute 
Valve  Cusp,  Rupture  of 

41.  Gradual  Onset 

Chronic  Diseases  in  general 
and  all  degenerative 
diseases. 

Acromegaly 

Amyloid 

Amyotrophic  Lat.   Sclerosis 

Aneurysm 

Ascites 

Ataxic  Paraplegia 

Bulbar  Paralysis 

Cancer 

Chorea 

Cirrhosis  of  any  Organ 

Dilatation  of  Stomach 

Enteric  Fever 

40-41 


ONSET 


25 


Gradual  Onset — continued 
General  Paralysis 
Hooping- Cough 
Landouzy-Dejerine    Para- 
lysis 
Locomotor  Ataxy 
Mastoiditis 
Myelitis,  Chronic 
Occupation  Neurosis 
Paralysis  Agitans 
Pernicious  Ansemia 


Phthisis 

Progressive  Muscular  Atro- 
phy 
Sclerosis,  Disseminated 
Tooth's  Paralysis 
Transverse  Softening  of  Cord 
Tuberculous  Meningitis 
Tumours,  Cerebral 

days  or  weeks 
Tumours  of  Cord 


41 


26 


PROPAGATION 


42.  PROPAGATION 


Sporadic  cases  of  most  of  these  diseases  occur  occasionally. 


43.  By  Epidemic 

Anterior    Poliomyelitis, 

Acute 
Asiatic  Cholera 
Beri-Beri 

Cerebro-spinal  Meningitis 
Chorea  Magna 
Cough,  Paroxysmal 
Dengue 
Diphtheria 
Dysentery 
Enteric  Fever 
Ergotism 
Erysipelas  (x) 
Erythema  Nodosum  (x) 
Hooping  Cough 
Influenza 
Malta  Fever 
Measles 
Mumps 
Paroxysmal   Hsernoglobin- 

uria 
Plague 

Pneumonia,  Acute  (x) 
Psittacosis 
Relapsing  Fever 
Roseola 
Rotheln 
Scarlatina 
Typhus 
Varicella 
Variola 
Yaws 


44.  By  Infection 

Actinomycosis 

Dengue 

Diphtheria 

Enteric  Fever 

Erysipelas 

Erythema  Infectiosum 

Glandular  Fever 

Hooping  Cough 

Influenza 

Measles 

Mumps 

Plague 

Roseola 

Rotheln 

Scarlatina 

Tuberculosis 

Typhus 

Varicella 

Variola 

Yaws 

Yellow  Fever 

Also,  according  to  some 
authorities,  Acute  Rheu- 
matism and  Acute  Pneu- 
monia. 

45.  By  Contagion 

Conjunctivitis 
Diabetes  (x) 
conjugal  form 

*Diphtheria 
Erysipelas 
Farcy 
Favus 

42-45 


PROPAGATION— SCHOOL  QUARANTINE 


27 


By  Contagion — continued 

Glanders 
♦Gonorrhoea 

Hospital  Gangrene 

Hydrophobia 
from  rabies 

Impetigo  contagiosa 

Leprosy 
slightly 

Malignant  Pustule 

Molluscum  contagiosum 

Porrigo 
children 

Purulent  Ophthalmia 

Ringworm 
*Scabies 
♦Soft  Sore 
♦Syphilis 

Trachoma 

Yaws 


46.  Infection  by  Clothing 
Diphtheria 
Influenza 

Hooping  Cough 

Measles 

Puerperal  Fever 

Rotheln 
♦Scarlatina 

Typhus 

Varicella 
♦Variola 

47.  Infection   by   '  Carriers  ■ 
Cholera 

Diphtheria 
Dysentery 
Enteric  Fever 

3  per  cent  of  cases 
Meningitis,  Cerebro- spinal 
Paratyphoid  Fever 
Yellow  Fever 


48.  SCHOOL  QUARANTINE 


49  After  Exposure  to  Infection 
('  Contacts ') 
Chicken-pox,  18  days 
Diphtheria,  12  days 
Enteric,  21  days 
Hooping  Cough,  21  days 
Measles,  16  days 
Mumps,  24  days 
Ringworm,  10-14  days 
Rotheln,  16  days 
Scarlatina,  14  days 
Small-pox,  18  days 
Typhus,  21  days 

In  the  case  of  Pertussis, 
Mumps,  Rotheln,  or 
Varicella,  one  day's 
quarantine  will  suffice 
for  a  pupil  after  transient 
exposure,  provided  he  has 
already  had  the  disease. 


50.  After  an  Infectious  Disease 

(The  body  and  clothes  hav- 
ing been  disinfected.) 

Diphtheria 

4  weeks  after  convalesence, 
provided  there  be  no 
albuminuria  and  no  dis- 
charge from  nose,  ears, 
eyes,  throat,  etc.  (the 
bacillus  is  often  found 
long  after  this).  For 
adults,  3  weeks  should 
suffice 

Enteric  Fever 

4  weeks  from  commence- 
ment of  defervescence 

Follicular  Tonsillitis 

5  days  45-50 


28 


SCHOOL  QUARANTINE 


After  an  Infectious  Disease 
— continued 

Hooping  Cough 

6  weeks  at  least  from  begin- 
ning of  whoop,  provided 
whoop  and  spasmodic 
cough  have  ceased 

Influenza,  Uncomplicated 

7  to  10  days  from  com- 
mencement 

Measles 

3  weeks  from  the  disappear- 
ance of  the  rash,  if  peeling 
and  cough  have  ceased 

Mumps 

4  weeks  from  the  commence- 

ment, if  all  swelling  have 
subsided 


Ringworm 

one  month  after  apparent 
cure 

Rot  n  elm 

2  to  3  weeks 

Scarlatina 

6  weeks  from  the  disappear- 
ance of  the  rash  if  there 
be  no  sore-throat,  or 
discharge  from  nose  or 
ear.  Desquamation  is 
considered  of  less  import- 
ance now  than  formerly 

Small-pox    and    Chicken- 
pox 

1  week  after  every  scab  has 
fallen  off 

Typhus 
5  weeks 


50 


DURATION 


29 


51.  DURATION 


52.  Acute  Diseases 

iEstivo-Malarial  Fever 

each  '  fit '  20  hours 
Ague 

cold  stage  10  to  60  min. 
hot  stage  2  to  6  hours 
sweating     stage     2     to     3 
hours 

Angeioneurotic  (Edema 

2  to  3  days ;  recurring 
every  3  weeks  or  so 

Angina  Pectoris 

from  minutes  to  hours 

Antitoxin  Rash 
incubation  1  week 

Apoplexy 

from  minutes  to  days 

Asthma,  Spasmodic 

from  one  hour  to  several 
days 

Bell's  Mania 

from  3  days  to  3  weeks 
Buhl's  Disease 

about  2  weeks 
Catalepsy 

minutes  to  hours  or  days 
Cerebro-spinal  Meningitis 

variable 
Chancre,  Hard 

incubation  3  to  5  weeks 
Chancre,  Soft 

incubation  a  few  hours  to 
a  week 

Cholera 

incubation  3  to  5  days 

Dengue 

invasion  3  days :  rash  1 
to  2  days ;  remission 
2  to  4  days 


Diphtheria 

incubation  |  to  6  days ; 
invasion  3  to  4  days ; 
membrane  1  to  7  days  ; 
paralysis  begins  8  to  12 
days  after  recovery 

Enteric  Fever 

incubation  3  weeks ;  in- 
vasion 11  days;  rash  10 
days 

Erysipelas 

incubation  15  to  60  hours 
Erythema  Scarlatiniforme 
little  or  no  incubation  stage ; 
eruption  4  to  5  days  or 
more 

Erythema  Infectiosum 
incubation  6  to  14  days 

Follicular  Tonsillitis 
incubation  4  days 

Gallstone  Colic 
u  a  few  hours 

Glandular  Fever 

incubation  7  days  ;  disease 
14  days 

Glanders 

incubation  3  to  8  days ; 
invasion  3  to  4  weeks ; 
developed  stage  2  to  20 
days 

Gonorrhoea 

incubation  3  to  5  days 
Herpes  Zoster 

u  10  to  20  days 
Hooping  Cough 

incubation  10  days ;  in- 
vasion 7  days 

Hydrarthrosis,  Intermittent 

4  to  5  days ;  interval  1 
month  or  more 

51-52 


30 


DURATION 


Acute  Diseases — continued 

Hydrophobia 

incubation  u  6  to  7  weeks, 
but  may  be  much  longer  ; 
disease  1  to  4  days 

Influenza 

incubation  2  to  3  days ; 
disease  4  to  5  days 

Malta  Fever 

incubation  8  to  14  days 

Measles 

incubation  10  to  12  days  ; 
invasion  3  to  4  days ; 
rash  4  to  6  days 

Meningitis,  Acute  Simple 

2  to  8  days 
Meningitis,  Post  Basic 

3  weeks  to  4  months 
Meningitis,  Tuberculous 

2  to  4  weeks 

Mumps 

incubation  8  to  21  days ; 
swelling  8  to  10  days 

Myelitis,  Acute 

a  few  hours 

Nephritis,  Acute 

3  to  10  weeks 
Paralysis,  Acute  Ascending 

a  few  days  when  fatal 
Paratyphoid  Fever 

from  12  days 

Periodic  Paralysis 

attack  a  few  hours  to  1  or 
2  days  (53) 

Petit  Mai 

a  few  seconds 
Plague 

incubation  3  to  5  or  7  days 


Pneumonia,  Acute 

incubation  48  to  70  hours  ; 
disease  5  to  7  days 

Pneumonia  Serpens 

2  to  3  weeks 

Poliomyelitis,  Acute 

incubation  8  days  ;  fever  1 
to  4  days ;  paralysis  on 
2nd  to  8th  day 

Psittacosis 

30  days  altogether ;  incuba- 
tion 7  to  12  days  ;  high 
fever  3  to  4  days 

Relapsing  Fever 

pyrexial  stage  5  to  7  days  ; 
sweating  8  to  9  hours  ; 
interval  6  to  8  days  or 
more ;  second  attack  3 
to  4  days 

Remittent  Fever 

5  to  14  days 
Roseola 

4  to  7  days — face  first 

Rotheln 

incubation  14  to  16  days, 
but  variable ;  invasion 
about  12  to  24  hours — 
longer  in  adults ;  rash 
3  days.  '  In  Fourth 
Disease '  the  incubation 
is  shorter  in  the  scarla- 
tiniform  type. 

Scarlatina 

incubation   8  to   9  days  ; 
invasion  |  to  2  days ; 
rash  3  to  5  days 

Spasmus  Nutans 

3  weeks  to  3  months 
Spinal    Meningeal    Haemor- 
rhage 

fatal  cases  a  few  hours 

Tetanus 

incubation  4  days  to  4 
weeks 

52 


DURATION 


31 


Acute  Diseases — continued 
Trypanosomiasis 

Temp,  above  normal  a  few 
days,  below  normal  a  few 
days 

Tuberculosis,  Acute 

a  few  days  to  a  few  weeks 

Typhus 

incubation  7  days  ;  invasion 

4  to  5  days  ;  rash  8  to 
9  days ;  defervescence 
3  days 

Varicella 

incubation  12  days ;  in- 
vasion a  few  hours  ;   rash 

5  to  10  days 

Variola 

incubation    12    days ;      in- 
vasion   2   days ;     rash    8 
to  10  days 
Vincent's  Angina 

about  one  week 
Yellow  Atrophy,  Acute 

2  to  3  weeks 
Weil's  disease 

10  to  15  days 
Quarantine  (see  49) 

53.  Chronic  Diseases 

Acromegaly 

10  to  20  years 
Addison's  Disease 

2  to  3  years 
Amyloid 

many  years 
Banti's  Disease 

many  years 
Brown-Sequard  Paralysis 

2  to  5  years 
Cancer,  Encephaloid 

about  1  year 


Cancer,  Scirrhus 

about  2  years 
Chloroma 

3  to  12  months 
Chorea 

1  to  4  months 
Chorea,  Huntington's 

10  to  30  years 
Distomiasis 

haemoptysis  10  to  15  years 
Exophthalmic  Goitre 

many  months  or  years 
Friedreich's  Disease 

many  years 
General  Paralysis 

a  few  months  to  2  years 

Guinea  Worm 

incubation  12  months 

Hereditary   Muscular   Atro- 
phy 
3  to  4  years 

Idiopathic    Muscular    Atro- 
phy 
many  years 

Kidney,  Contracted 

from  4  to  10  years 
Landouzy-Dejerine       Para- 
lysis 

for  many  years 
Leukaemia 

from  ^  to  7  years 
Locomotor  Ataxy 

from  1  to  many  years 
Lymphadenoma 

about  2  years 
Meningitis,  Post  Basic 

1  to  4  months 

52-53 


32 


DURATION 


Chronic  Diseases — continued 

Miculi.cz'  Disease 

2  months  to  10  years 

Milroy's  Disease 

life-long ;     but   with   inter- 
current acute  crises 

Morvan's  Disease 

for  years 
Myelitis,  Chronic 

^  to  10  years 
Nephritis,  Chronic 

1  to  4  years 
Periodic  Paralysis 

healthy  interval   1   day  to 
1  year 

Pharyngomycosis 

months  or  years 
Primary  Spastic  Paraplegia 

for  many  years 
Sclerosis,  Disseminated 

5  to  10  years 
Syringomyelia 

5  to  20  years 
Traumatic  Neurasthenia 

latent  1  or  more  weeks 
Traumatic  Spondylitis 

latent  a  few  weeks 
Trypanosomiasis 

from  4  to  8  months 

Yaws 

2  to  4  months  or  more 


54.  Recurrence,   Periodical   or 
Occasional 

Ague 

Angioneurotic  (Edema 

Angina,  Abdominal 

„        (Esophageal 

,,         Pectoris 
Appendicitis 
Asthma,  Spasmodic 
Bronchitis 
Catalepsy 

Cyclical  Vomiting  of 
Children 
intervals  irregular 

Eczema 
Epilepsy 
Hay  Fever 
Henoch's  Purpura 
Hydrarthrosis,  Intermittent 
Intermittent,  Pernicious 
Menstrual  Disorders 
Migraine 
Mittelschmerz 
inter-menstrual 

Neuralgia 

Paroxysmal   Hsemoglobin- 

uria 
Periodic  Paralysis 
Pseudangina 
Psoriasis 
Relapsing  Fever 
Rheumatism 

(See  32  and  301) 


53-54 


SLEEP 


33 


55.  SLEEP 

The  statements  that  patients  make  as  to  the  duration  of  sleep 
are  usually  unreliable ;  even  the  fact  that  they  have  heard  the 
clock  strike  does  not  preclude  sleep  so  light  that  this  sound 
sufficed  to  wake  them  momentarily.  The  standard  duration 
of  sleep  necessary  for  adults  is  8  to  9  hours ;  for  old  people,  5  to  6 
hours,  and  for  children,  12  hours. 


56.  Day  Restlessness 
Alcoholism,  Chronic 
Dysentery 
Dyspnoea  (1223) 
Enteric  (3rd  week) 
Glossitis 
Hydrophobia,  I. 
Hyperemia  of  Brain 
Laryngitis 

Meningitis,  Simple,  I. 
Myocarditis,  Acute 
Tapeworm 
Throat  Affections 


57.  Sleeplessness  or  Insomnia 

Anaemia,  Severe 
Aortic  Regurgitation 
Arterio- sclerosis 

with  morning  somnolence 
Cold  Extremities 
Collapse  of  Lungs 
Constipation 
Delirium  Tremens 
Dilatation  of  Heart 
Dysentery 
Dyspepsia 
Dyspnoea  (1223) 
Flatulence 
Gastritis,  Chronic 
Gout 

Hypereemia  of  Brain 
Kidnev   Cirrhosis  of 


Liver,  Cirrhosis  of 

Mania 

Melancholia 

Meningitis,  I. 

Neurasthenia 

Paralysis,  General 

Pneumonia,  Acute 

Rickets 

Stomach,  Atony  of 

Teething 

Trichinosis 

Valvular  Disease 

Other  causes  are  mental 
strain  or  emotions  ;  pain, 
late  meals,  late  use  of  tea 
or  coffee,  and  unconscious 
hunger. 


58.  Night  Terrors 

The  child  wakes  up  in  the 
night,  shrieking  and  be- 
wildered. 

Adenoids 

Colitis 

Dentition 

Epilepsy 

Frights 

Hysteria 

Indigestion 

Lithaemia 

Mucous  Colitis 

Rheumatism 

55-58 


34 


SLEEP 


Night  Terrors — continued 
Syphilis,  Hereditary 
Tonsils,  Enlarged 
Worms 

Some  cases  are  accounted 
for  by  a  real,  but,  to 
the  patient,  an  '  uncanny ' 
noise. 

59.  Nightmare  and  Starting 

Adenoids 

Aortic  Regurgitation 

Delirium  Tremens 

Dyspepsia 

Emboli,  Small  Cerebral 

Encephalitis,  i. 

Hyperemia  of  Brain 

Hypertrophy  of  Heart 

Meningitis 

Mental  Exhaustion 

Neurasthenia 

Teething 

Tonsils,  Enlarged 

Worms 

Nightmare  is  often  caused 
by  insufficient  bed-clothes 
or  by  the  head  slipping 
off  the  pillow. 

60.  Narcolepsy 

A  sudden  paroxysm  of  sleep 
in  the  midst  of  some 
occupation. 

Hysteria 
Jaundice 

Nephritis,  Chronic 
Petit  Mai 
Stomach,  Overloaded 

61.  Drowsiness  or  Stupor 

Abscess  of  Brain,  I. 
Acute  Yellow  Atrophy 


Alcoholism  Acute,  II. 

„  Chronic 

Anaemia  (x) 
Asphyxia 
Atony  of  Stomach 
after  meals 

Bromism 

Cerebellar  Disease 
Chlorosis 
Cold,  Intense 
Concussion  of  Brain 
Cyanosis 
Diabetic  Coma 
Dilatation  of  Heart 

daytime 
Dyspnoea  (1223) 

severe  cases 

Encephalitis 
Embolism  (clot) 
(fat) 
Epilepsy,  n. 
Gangrene  of  Lung 
Hsematoma  of  Dura  Mater 
Hsemoglobinuria,  Infantile 
Hsemophilia,  in. 
Hydrocephalus 
Intermittent  Fever 
end  of  paroxysm 

Intermittent,  Pernicious 
Jaundice  (392) 
Lithsemia 

after  meals 

Liver  Disorders 
Meningitis,  Cerebrospinal,  II. 

,,  Simple,  it. 

„  Tuberculous,  n. 

Narcotic-poisoning 
Neurasthenia 
Plague 

58-61 


SLEEP 


35 


Drowsiness     or    Stupor 
continued 
Remittent  Fever 
Septicaemia,  in. 
Softening  of  Brain 
Spina  bifida,  in. 
Trypanosomiasis 
Typhic  State  (62) 
Typhus 
Uraemia 


62.  Typhic  State  or  '  Typhoid 
State ' 

The  expression  '  Typhoid 
State '  is  misleading  as 
it  refers  to  Typhus,  not 
Typhoid  Fever. 

*Acute  Yellow  Atrophy 

Anthrax 

Appendicitis,  in. 

Dysentery  (term.) 

Endocarditis,  Septic 
*Enteric,  Severe 

Erysipelas,  Severe 
*Extravasation  of  Urine 

Hepatic  Abscess 

Hydatids,  Suppurating 

Jaundice,  Severe 

Pernicious  Malaria 

Phosphorus-poisoning 

Plague 
^Pneumonia,  Septic 

Ptomainism 

Portal  Thrombosis,  Suppura- 
ting 

Scarlatina,  Malignant 
*Septiccemia 

Typhus,  Malignant 

Variola,  Malignant 
(See  1829) 


63.  Coma  Vigil 

The  patient  rouses  when 
spoken  to,  but  immedi- 
ately relapses  again  into 
coma. 

Commencing  Coma  (64) 
Delirium  Tremens 
Enteric  Fever,  in. 
Septicaemia 
Typhic  State 

64.  Coma 

A  deep  stertorous  sleep  from 
which  it  is  impossible  to 
rouse  the  patient. 

Addison's  Disease,  in. 
*  Alcoholism,  Acute 

temperature   subnormal 

Amyloid,  in. 
*Apoplexy 
^Asphyxia 
Atrophy,  Acute  Yellow 

„         of  Kidney,  Acute 
Cholangitis,  Chronic  Fibrous 
^Compression  of  Brain 
Coal-gas-poisoning 
Diabetes,  in. 

Disseminated  Sclerosis,  in. 
Embolism  of  Brain 
Encephalitis,  ni. 
Erysipelas,  Severe 
Exposure  to  Cold 
Fat  Embolism 
*Fracture  of  Skull 
General  Paralysis,  in. 
Glanders,  ni. 
Gout,  in.  (x) 

Haematoma  of  Dura  Mater 
Hyperpyrexia 
Jaundice  (x) 
Meningisme 

61-64 


d  2 


36 


SLEEP 


Coma. — continued 

Meningitis,  in. 

simple,     tuberculous,     or 
cerebro -spinal 

Myxcedema,  in. 
Narcotic-poisoning 
Pernicious  Anaemia,  in. 
„  Intermittent 

Remittent  Fever 

(severe) 
Scarlatina  maligna 
Softening  of  Brain,  Exten- 
sive 
*Sunstroke 
Thrombosis  of  Brain 
Tumours  of  Brain,  in. 
*Ursemia 
Variola  maligna 

65.    Unconsciousness    without 

Coma 
Addison's  Disease 
Anaemia  of  Brain 
Anaesthesia,  Incomplete 
*Aortic  Stenosis 
Atrophy  of  Heart 
Bell's  Mania 
Catalepsy 

incomplete 

Collapse 

incomplete 
Concussion  of  Brain 

rarely  complete 


Epilepsy,  n. 

except  Jacksonian  form 

Ergotism,  Spasmodic 

Faints 
*  Fatty  Degeneration  of  Heart 

Gouty  Heart 

Hypnotism 

Hysteria 

the  eyelids  often  quiver 

Hy  stero  -  epilepsy 
*Internal  Haemorrhage 

Malformation  of  Heart 
*Malingering 

Shock 

Sunstroke 

Syphilitic  Heart 

Syncope 

Trance 

(See  Coma,  64  ;  Faintness, 
230) 

66.  Momentary     Unconscious- 
ness 

Cerebral  Embolism 

minute  plug 
Cerebral  Haemorrhage 
minute  clot 

General  Paralysis 
Laryngeal  Vertigo 
Petit  Mai 
Stokes-Adams'  Disease 


64-66 


APPETITE 


37 


67.  APPETITE 


68.  Increased  (Bulimia) 

Bulimia  Neurotica 

Chlorosis 

*Convalescence  from  Fevers 
♦Diabetes 

Dilatation  of  Stomach  (x) 

Epilepsy- 
Ergotism 

Exophthalmic  Goitre 

Gastralgia 

Gastritis,  Chronic  (x) 

Hooping  Cough 

Hyperchlorhydria 

Hysteria 

Insanity 

Iodism 

Neurasthenia  (x) 

Pregnancy 

Tumour,  Cerebral 

Softening,  Cerebral 

Ulcer  of  Stomach  (x) 

Worms 


69.  Diminished  (Anorexia) 

Abscess  of  Liver 

Ague  (prsem.) 
♦Alcoholism,  Chronic 

Anaemia 
*Anorexia  nervosa 

Arsenic  -poisoning 


Atony  of  Stomach 

Atrophy  of  Stomach 
*Cancer  of  Stomach  or  Liver 

Cirrhosis  of  Stomach 

Cceliac  Disease 

Constipation 

Coryza 

Cystitis 

Delirium  Tremens 

Duodenal  Catarrh 

Dysentery,  in. 

Empyema 
*Faecal  Accumulation 

Gastritis,  Acute 

Hepatitis,  Acute 
♦Influenza 

Melancholia 

Peritonitis,  Chronic 
*Pyrexial  Affections  (295) 

Suppuration 

70.  Morbid  (Pica) 

The  patient  eats  nails, 
needles,  or  even  dis- 
gusting substances. 

Anaemia 

Chlorosis 
♦Hysteria 

Idiocy 
♦Insanity 

Pregnancy 


67-70 


38 


THIRST 


71.  THIRST 

This  is  usually  the  expression  of  deficiency  of  water,  or  of  excess 
of  salts,  in  the  blood,  and  occurs,  therefore,  where  there  is  loss  of 
fluid  by  sweating,  vomiting,  diarrhoea,  polyuria,  haemorrhage  or  high 
temperatures  on  the  one  hand,  and  much  salted  food  on  the  other. 


72.  Increased 

Abdominal  Injuries 
Ague 

Arsenic -poisoning 
Cancer  of  Stomach 
Cholera 
*Diabetes 

,,         Insipidus 
„         '  Phosphatic  ' 
Diarrhoea 

Dilatation  of  Stomach 
Gastritis,  Acute  and  Chronic 


Glossitis 

Gout 
*Ha3inorrhage 
*Hyperidrosis 

Hysteria 

Intestinal  Obstruction 

Kidney,  Cirrhosis  of 
*Pyrexial  Diseases  (295) 

Sunstroke 

Tetanus 

Xerostoma 


71-72 


MENSTRUATION 


39 


73.  MENSTRUATION 

The  menses  usually  appear  about  the  age  of  fourteen,  but  they 
have  been  known  to  begin  as  early  as  eight.  The  average  age 
for  their  cessation  is  forty-six,  though  they  are  usually  irregular 
in  their  appearance  for  the  last  two  years  or  more,  and  arp  normally 
absent  during  pregnancy  and  lactation. 


74.  Amenorrhea  (Menses  Ab- 
sent) 

The  menses  may  fail  to 
appear  owing  to  con- 
genital defects  or  to 
injuries  received  in  child- 
hood (Primary  Amen- 
orrhea) ;  or,  they  may 
fail  to  re-appear  (Secon- 
dary Amenorrhea). 

Absence  of  Uterus,  Ovaries, 
or  Vagina 

Acromegaly,  n. 

Addison's  Disease 

Alcoholism,  Chronic 
♦Anaemia 

Anorexia  Nervosa 

Atrophy  of  Uterus 

Cachexia,  Cancerous 
„         Syphilitic 

Cervical  Catarrh 
♦Chlorosis 

Colitis 

Cretinism 
♦Diabetes 

Ectopic  Gestation 

Endometritis 

Enteric  Fever 

Exophthalmic  Goitre 

Fibroids 

Hysteria 

Imperforate  Hymen 
Os 


Lead-poisoning 
Leukaemia 
Lymphadenoma 
Malarial  Cachexia 
Melancholia 
Mercurialism 
Metritis 
Morphinism 
Myxcedema 
Nephritis,  Chronic 
Obesity 
Oophoritis 

Ovarian  Cysts,  Double 
Parametritis 
Pelvic  Adhesions 
♦Phthisis 
Renal  Insufficiency 
Rheumatism,  Acute 
Scarlatina 
Superinvolution 
Tuberculous  Kidney 
Ulcer  of  Stomach 

The  menses  may  also  fail 
to  appear  owing  to  change 
of  air  or  of  occupation, 
to  frights,  and  to  intel- 
lectual strain  or  worry. 


73-74 


40 


MENSTRUATION 


75.  Dysmenorrhea    (Painful 
menstruation) 

*Anaemia 
Anteflexion 
Cancer 

Cervix,  Long  Conical 
Chlorosis  (x) 
Congestion,  Uterine 

dull  pain 
Deflection  of  Canal 
Ectopic  Gestation 
shreds  or  decidua  vera 
*Endometritis 
Fibroids,  Uterine 
Gout 

Hypertrophy  of  Uterus 
Neuralgia 
Neurosis 
Obstruction 
from    clots,    shreds,   mem- 
branes, etc. 

Oophoritis 
Ovary,  Small  Cystic 
Peritonitis,  Pelvic 
Polypus 
*Retroflexion 
Retroversion 
Rheumatism 
Salpingitis 
Stenosis  of  Canal 

76.  Menorrhagia    (Excessive 
periodic  flow)  and 

77.  Metrorrhagia    (Intermedi- 
ate Haemorrhage) 

*Abortion 

Abraded  Os 

Adenoma  Internum 

Alcoholism 

Anteflexion 
*Cancer  of  Uterus 

esp.  near  menopause  i 


Chlorosis  (x) 
Cirrhosis  of  Liver 
Congestion  of  Uterus 
Ectopic  Gestation 

*Endometritis 
Emmenagogues 
Exophthalmic  Goitre 

*Fibroids 

Fungous  Degeneration 

Granular  Os 

Hematocele 

Haemophilia 

Heart  Disease 

Hypertrophy  of  Uterus 

Inversion 
*Lead-poisoning 

Leukaemia 

Malaria 

Menopause 

Metritis  (x) 
*Miscarriage 

Myxcedema 

Nephritis 

Oophoritis 

Ovaries,  Displaced 

Ovarian  Growths 

Pelvic  Cellulitis 
,,      Peritonitis 

Phosphorus-poisoning 

Plethora 
*Polypus 
Prolapsus  Uteri 
Purpura 
Pyometra 
Retained  Decidua 
Retroflexion 
Retroversion 
Salpingitis 
Sarcoma 
Scurvy 
Subinvolution 
Syphilis  j 

75-77 


MENSTRUATION 


41 


Menorrhagia    and  Metror- 
rhagia— continued 
Uterus,  Tuberculosis  of 
Vaginitis,  Senile  Granular 
Variola,  Malignant 
Yellow  Atrophy,  Acute 

78.  Dyspareunia(PainfulCoitus) 
Anal  Fissure 
Bartholinitis 
Caruncle 

Cystitis 
Gonorrhoea 


Haemorrhoids 

Hymen,  Partly  Persistent 

Hymeneal  Orifice,  Inflamed 

Kraurosis  Vulva? 

Labial  (Edema 

Metritis 

Neuritis,  Pudic 

Oophoritis,  Adhesive 

Ovary,  Prolapsed 

Perinatal  Laceration 

Urethritis 

Vaginismus 

Vulvitis 


76/77-78 


42 


DISCHARGES 


79.  VAGINAL  DISCHARGES 


80.  White  Discharge  (Leucor- 
rhoea) 

*  Anaemia 

Anteflexion  (x) 
Bartholinitis 

duct  external  to  hymen 

*Cervical  Catarrh 

*  Endometritis,  Chronic 
Erosions,  Cervical 
Fibroid  Tumours 
Gleet 

'^Gonorrhoea 
Granular  Cervix 
Hypertrophied  Cervix 
Metritis,  Chronic 
Pelvic  Peritonitis 
Polypus 
Prolapsus  Uteri 
Salpingitis 
Sarcoma  of  Uterus 
Tubal  Colic 
intermittent 

Vaginitis,  Catarrhal 
„       Granular 
Worms  (children) 

81.  Sanguineo-purulent     Dis- 
charge 

*Cancer  of  Uterus 
*Endometritis,  Hemorrhagic 
*Endometritis,  Purulent 
*Endometritis,  Septic 


Endometritis,  Senile 
Metritis,  Acute 
Pelvic  Abscess 

discharging 
Polypus 

82.  Offensive  Discharge 

Abscess,  Pelvic 
Cancer  of  Uterus 
*Death  of  Foetus 
Endometritis,  Chronic 
„  Senile 

,,  Septic 

Fibroids,  Sloughing 
Polypus,  Cervical 
Puerperal  state 
moderately    so 
*Retained  Decidua 

83.  Shreds  and  Membranes 

*Abortion 

Diphtheria 

Ectopic  Gestation 
*Membranous    Dysmenor- 
rhea 
*Miscarriage 
*Puerperal  Decidua 

84.  Emission  of  Gas 

Garrulitas  Vulvae 

noisy 
Recto-Vaginal  Fistula 


79-84 


SENSIBILITY— PAIN  43 


85.  SENSIBILITY 

The  sensory  paths  are  divided  into — 

Protopathic  Cutaneous  Sensibility — including  pricking,  fara- 
disation, freezing,  and  burning. 

Epicritic  Cutaneous  Sensibility,  which  includes  light  touches, 
and  fine  differences  in  temperature. 

Deep  Sensibility  comprising  recognition  of  pressure  pain, 
sensation  from  muscles  and  joints,  and  the  vibration  sense. 
The  fibres  run  chiefly  with  the  muscular  nerves. 

When  a  peripheral  nerve  is  divided,  a  small  and  well-defined 
area,  in  which  both  epicritic  and  protopathic  sensibility  are 
absent,  is  surrounded  by  a  large  ill-defined  area  in  which  only 
epicritic  sensibility  is  abolished.  But,  when  the  nerve-root 
is  divided,  the  areas  of  epicritic  and  protopathic  sensibility 
coincide.  In  cord  lesions,  there  are  no  partial  changes  ;  it  is 
a  case  of  all  or  none  ;  whether  with  sensibility,  temperature - 
sense,  or  position-sense. 


86.  PAIN 

Pain  due  to,  or  increased  by,  the  breaking  down  of  resistance 
in  the  higher  centres  is  commoner  on  the  left  side.  Thus, 
the  pain  from  old  uterine  cancer  is  six  times  commoner  on  the 
left  than  on  the  right  side.  Pressure  on  the  trunk  of  a  nerve 
produces  pain  or  tingling  at  the  nerve  termination. 

It  is  often  difficult  to  estimate  the  degree  of  pain  felt,  for 
the  patient's  statement  cannot  always  be  relied  upon.  Some 
information  may  be  obtained  by  a  scrutiny  of  the  expression, 
and  some  from  the  time  spent  in  sleep.  If  a  patient  professes 
to  be  in  constant  acute  pain,  and  nevertheless  sleeps  four  or  five 
hours  at  a  stretch,  credence  must  be  witheld.  Further,  were 
anything  like  intense  pain  present,  evidence  of  it  would  be  found 
in  the  hard  pulse,  the  quickened  breathing,  the  dilated  pupils, 
and  the  clammy  skin.  On  the  other  hand  some  patients  make  too 
light  of  the  pain  felt.  The  pain  in  hysterical  and  neurasthenic 
patients  is  less  marked  when  the  attention  is  diverted.  It  is 
difficult  to  determine  the  seat  of  pain  in  an  infant,  but  the 
nature  of  the  cry  (1233),  the  expression,  and  Jadelot's  Traits 
(408),  will  usually  provide  a  clue. 

86-86 


44 


PAIN 


87.  General  Pain 

'  Pain  all  over  ' 
Anaemia 
Anterior  Poliomyelitis,Acute 

onset 

*Dengue 

Diabetes 

Fevers,  Onset  of 

'  Growing  Pains  ' 
u  rheumatic 

Gout 

Infantile  Scurvy 
*Influenza 


Lead-poisoning 
Lithamiia 
Locomotor  Ataxy 
Meningitis,  Spinal 
Multiple  Neuritis 
Nephritis,  Chronic 
Osteomalacia 
Periarteritis  Nodosa 
*Rhcumatism 
Rickets 
Scurvy 
Syphilis 
Trichinosis 


88.  REGIONAL  PAIN 

Headaches. — The  symptom  is  too  common  to  be  of  much  value  ; 
but  it  may  be  noted  that  cerebral  headaches  are  worse  at  night 
and  often  paroxysmal.  High  tension  headaches  and  those  con- 
nected with  gastric  disturbance  are  of  a  throbbing  character  and 
are  often  relieved  by  the  recumbent  posture.  Of  headaches  due 
to  eyestrain,  those  arising  from  Astigmatism  are  usually  worse 
in  the  morning,  while  those  due  to  other  causes  are  worse  in  the 
evening. 


89.  Frontal  Headache 

Adenoids 

*Anaernia 

Enteric  Fever 

ceasing     when     delirium 
appears 

Eyestrain 
Fevers 

prodromal  stages 

*Frontal  Sinus  Obstruction 
Gastritis 
Glaucoma 

Hsematoma  of  Dura  Mater 
Iritis 
Lithaemia 
Malaria 
Neurasthenia 
Periostitis 


Syphilitic  Nodes 
Thrombosis   of   Sup. 

Sinus 
Trigeminal  Neuralgia 
Uraemia 


Long. 


90.  Occipital  Headache 

*Adenoids 
*Asthenopia 

Buhl's  Disease 
^'Cerebellar  Tumours 
'  headache  of  effort ' 

Cerebro-spinal  Meningitis 

Cervico-occipital  Neuralgia 

Cirrhosis  of  Kidney 
*Constipation 

Diabetes 

87-90 


PAIN 


45 


Occipital      Headache — con- 
tinued 

Epilepsy 

Eyestrain 

Gout 

Locomotor  Ataxy 

Naso-pharyngeal  Disease 
Legal' s  Disease 

Nephritis,  Chronic 
*Ncurasthenia 

Pharyngitis 

Rheumatism 

Sphenoidal  Disease 
*Syphilis 

Syringomyelia 

Tongue  Lesions,  Basal 

Uterine  Diseases 

(See  Nucha,  100) 

91.  Unilateral  Headache 

Adenoids 

Antral  Abscess 

Bone,  Diseased 

Cancer  of  Tongue 

Carious  Teeth 

Dysmenorrhea  a 

Eyestrain,  Unilateral 

Gouty  State 
*Hysteria 
clavus 

Mastoid  Abscess 
*Migraine 

Nephritis,  Chronic 

Otitis  Media 

Polypus,  Nasal 
*Trigeminal  Neuralgia 
paroxysmal 

Tumour,  Cerebral 
*Wax  in  Meatus 


92.  Pain  at  Vertex 

Anaemia 

Chlorosis 

Constipation 

Epilepsy 
*Hysteria 
*Neurasthenia 

'  helmet  headache  ' 

Uterine  Diseases 


93.  Unclassified  Headaches 

Abscess  of  Brain 

Addison's  Disease 

Ague 

Alcoholism 
*Amenorrhcea 
*Ana3mia 

Apoplexy  (praam.) 

Arsenic-poisoning 

Asthma 

Atony  of  Stomach 

Aura  Epileptica 

Catalepsy 

Chlorosis 

Cinchonism 

Cirrhosis  of  Kidney 
worse  in  morning 

Compression  of  Brain 

Congestion  of  Liver 
*Constipation 
*Coryza 

Dengue 

Diabetes 

Dilatation  of  Stomach 

Disseminated  Sclerosis 

Duodenal  Catarrh 
*Dysmenorrhoea 

Dyspepsia 
-Dyspnoea  (x)  (1223) 

90-93 


46 


PAIN 


UNCLASSIFIED      HEADACHES — 

continued 
Embolism,  Cerebral 
Encephalitis 
Epilepsy 
Erysipelas 

Exophthalmic  Goitre 
General  Paralysis 
Glandular  Fever 
Glaucoma 
Gouty  state 

Hsematorna  of  Dura  Mater 
circumscribed 

^Haemorrhage 
*Hay  Fever 

Hereditary    Cerebellar    At- 
axy 

Hydrocephalus 

Hyperoemia  of  Brain 

Hypertrophy  of  Brain 
„  of  Heart 

^Hysteria 

*Incubation  of  Fevers 
^Influenza 

Iritis 

Jaundice 

Lactation,  Prolonged 

Lead-poisoning 

Leontiasis  Ossea 

Leucorrhcea 

Litheemia 

Measles 

Meningitis 

„  Cerebro-spinal 

Menopause 

Mental  Overstrain 

Morphinism 

Nephritis 
*Neuralgia 
*Neurasthenia 

Oophoritis 


Oxaluria 

Pachymeningitis 

Plague 

Pneumonia,  Acute 

Polycythsemia,      Splenome- 
galic 

Polypus,  Nasal 
*  Pyrexia  (295) 

Relapsing  Fever 

Remittent  Fever 
*Rheumatism 

Softening  of  Brain 

Spur  of  Septum 

Sunstroke 

Syphilis 

Tapeworm 
*Tension,  High  Arterial 

Thrombosis,  Cerebral 

Tumour  of  Brain 

except  when  in  c.  callosum 

Turbinated  Bone,  Enlarged 

Typhus 

Uraemia 

Valvular  Disease 

Variola,  I. 

Weil's  Disease 

Headache  is  often  caused 
by  impure  air,  fatigue, 
flatulence,  and  depression 
after  excitement.  It  is 
also  said  to  be  caused  by 
imperfect  coagulability 
of  the  blood. 


94.  Eyeballs 

Conjunctivitis 
*Coryza 
*Eyestrain 

Glaucoma 

Injuries 

Iritis 

93-94 


PAIN 


47 


Eyeballs — continued 
Keratitis 
Migraine 

*Neuralgia  of  Fifth  Nerve 
Ophthalmoplegia  interna 
Panophthalmia 
Sphenoidal   Sinusitis 
(See  Photophobia,  561) 


95.  Earache 

*  Abscess,  Alveolar 

,,         Mastoid 
Anaemia 

Aneurysm  of  Innominate 
Caries  of  Temporal  Bone 
Chloroma 
Eczema  of  Meatus 

*  Foreign  Body  in  Meatus 
Furuncle  in  Meatus 
Gland,  Inflamed  Mastoid 
Herpes  Auris 

Injuries 

Larynx,  Ulcer  of 

Mastoiditis 

Mumps 

Neuralgia,  Trigeminal 
*Otitis  Media  or  Interna, 
Acute 

Perichondritis,  Acute 

Pharynx,  Ulcerated 

Polypus 
*Pulpitis,  Dental 
lower  molar 

Rheumatism,    Temporo- 

maxillary 
Sphenoidal  Sinusitis 
*Teething 
Tongue,  Cancer  of 

,.       Ulcer  of 
Toxaemia 


96.  Nose 
*Antral  Disease 
*Foreign  Body 

*  Frontal  Empyema 
Glanders 
Syphilis 

97.  Upper  Jaw 

*  Abscess,  Alveolar 

„        of  Pulp 

Antrum,  Disease  of 
*Cancer 

Caries 

Exostosis,  Dental 
*Neuralgia,  Sup.  Max. 

Periodontitis 

Periostitis 

Pulpitis 

S  ah  vary  Calculus 

98.  Lower  Jaw 

*  Abscess,  Alveolar 

*  Abscess  of  Pulp 
Actinomycosis 
Caries 

Exostosis,  Dental 
Fracture 
Mumps 

*Neuralgia,  Inf.  Max. 
Periodontitis 
Pulpitis 
S  ah  vary  Calculus 

99.  Neck 

*Abscess 

Caries,  Cervical 

Glandular  Fever 

Innominate  Aneurysm 

Lymphadenoma 

Polymyositis 
*Rheumatism 

Serratus  Palsy 
*Strain 

Syringomyelia        94-99 


PAIN 


100.  Nape  of  Neck  (Nucha) 
Cerebellar  Disease 
Cerebrospinal  Meningitis 

♦Cervico-occipital  Neuralgia 

Muscles,  Sprained 
*Neurasthenia 

Pharyngitis 

Refraction  Error 
♦Rheumatism 

Spinal    Meningeal    Haemor- 
rhage 

Tetanus 

101.  Throat 

Cancer 

Concretions  in  Tonsil 
Crico-arytenoid  Arthritis 
♦Diphtheria 


♦Foreign  Body 
Laryngitis 

♦Nasopharyngeal  Catarrh 
Pharyngitis 
Poisoning  by — 
Aconite 
Cantharides 
Conium 
Corrosives 
Irritants 
Post-pharyngeal  Abscess 
*  Quinsy 
♦Scarlatina 
♦Tonsillitis 
Tuberculous  Pharyngitis 

„  Tonsillitis 

♦Uvula,  Swollen 

(See  Dysphagia,  693) 


102.   PAIN  IN  BACK 


103.  Spinal  Pain 
Apoplexy,  Spinal 
circumscribed 

Aneurysm,  Abdominal 
„  of    Descending 

Aorta 

Cancer  of  Liver 
„        of  Spine 

Caries  of  Vertebras 

Cerebro -spinal  Meningitis 

Compression  of  Cord 

Disseminated  Sclerosis 
esp.  the  paraplegic  form 

External  Spinal  Pachymen- 
ingitis 

Hyperaemia  of  Cord 
♦Hysteria 

Meningitis,  Internal  Spinal 

Mollities  Ossium 


Myelitis 

♦Neuralgia 
♦Neurasthenia 
Osteomyelitis 
Osteitis  Deformans 
Rheumatoid  Arthritis 

esp.  cervical 
Salpingitis 

esp.  11th  and  12th  dorsal 

Spinal    Meningeal    Haemor- 
rhage 

Spondylose  Rluzomelique 

Sprains 

increased  by  rotation 

Syringomyelia 
Traumatic  Spondylitis 
Tuberculous  Spinal  Menin- 
gitis 

100-103 


PAIN 


49 


Spinal  Pain — continued 
Tumour  of  Cord 
*Ulcer  of  Stomach 
lumbo- dorsal 
(See  Interscapular  Pain,  107) 

104.  Coccygeal  Pain 

Pain  at  extremity  of  spine 
*Coccygodynia 

Fissure  of  Anus 

Fistula 
*Haemorrhoids 

Injuries 

Periproctitis 
*Rheumatism 

Sacro-coccygeal    Tubercu- 
losis 
*Uterine  Diseases 

105.  Sacral  Pain 

Pain  at  lower  part  of  spine. 

Ataxic  Paraplegia 

Cancer  of  Rectum,  Uterus, 
or  Testis 
*Cervical  Catarrh 
*Dysmenorrhcea 
*Endometritis 

Fibroids 
*Flexions  of  Uterus 

Haemorrhoids 

Hip  Disease 

Inversion  of  Uterus 

Metritis 
*Neuralgia 

Orchitis 

Ovarian  Disease 

Pelvic  Peritonitis 
*Prolapsus  Uteri 

Retroversion 

Sacro-iliac  Disease 

Salpingitis 


Sarcoma  of  Uterus 
*Scybala 
Spinal  Apoplexy 
Subinvolution 
Tumours  of  Uterus 
Venery,  Excessive 

106.  Lumbar  Pain 

Abscess,  Lumbar 
,,        Perinaeal 
„        Rectal 
Aneurysm,  Abdominal 
Appendicitis 
*Calculus,  Renal 
unilateral 

*Calculus,  Vesical 

Cancer  of  Spine 
„       of  Stomach 

Caries  of  Spine 

Cauda  Equina,  Tumour  of 

Chorea 

Chyluria 

Curvature,  Lateral 
*Cystitis 

Dengue 

'  Diabetes,  Phosphatic  ' 

Dysmenorrhcea 

Embolism,  Renal 

Enteroptosis 
*Faecal  Accumulation 
*Fatigue 

Flatulence 
*  Gravel 

Hernia 

Hydatids 

Hydronephrosis 

Infantile  Paralysis 

onset 
*Influenza 

Kidney,  Floating 
„         Tuberculous 

103-106 


50 


PAIN 


Lumbar  Pain — continued 
Kidney,  Cancer  of 
Lithoemia 
Locomotor  Ataxy 
crisis 

♦Lumbago 

Meningitis,  Internal  Spinal 
„  Tuberculous 

Spinal 
Miscarriage 
Nephralgia 
Nephritis,  Acute 

„  Suppurating 

Neuralgia,    Lumbo-abdomi- 

nal 
Neurasthenia 
Oophoritis 
Pachymeningitis,     External 

Spinal 
Parasite  of  Kidney 
♦Parturition 
Perinephritis 
Pleurisy  (onset) 
Polycythemia,      Splenome- 

galic 
Prostatitis 
Pyelitis 


Pyonephrosis 

Remittent  Fever 

Retroflexion 

Thrombosis,  Renal 

Tumour,  Abdominal 

Typhoid  Spine 

Variola,  I. 
***  A  common  cause  of  lumbar 
pain    is    the    wearing    of 
high-heeled  boots. 

107.  Interscapular  Pain 

Aneurysm     of     Descending 

Aorta 
Atony  of  Stomach 
Cancer  of  Stomach 

cardiac  end 
Caries  of  Dorsal  Spine 
Cerebellar  Tumour 
Cirrhosis  of  Stomach 
♦Flatulence 
*Gastric  Irritation 
,,       Ulcer 
Gastritis 

Mediastinal  Abscess 
,,  Tumour 

♦Rheumatism 
Tumour  of  Cord 


108.  PAIN  IN  CHEST 


109.  Mamma 

♦Abscess,  Mammary 

„        Retromammary 
,,        Tuberculous 
*Cancer 
♦Cracked  Nipple 

Cyst,  Multiple 

Ectopic  Gestation 

Hysteria 

Lobular  Induration 

Mastitis,  Chronic 

Menstruation  (x) 


♦Neuralgia 

Obstructed  Lacteal  Duct 

Ovarian  Disease 
♦Pregnancy 

110.  Sternum 

Aneurysm,  Thoracic 

Angina  Pectoris 

retro-sternal      (Beaume's 
Sign) 

Aortitis 
Bronchial  Calculus 

106-110 


PAIN 


Til 


Stern  um — continued 

Bronchial  Glands,  Enlarged 
Bronchitis,  Acute,  I. 
Caries  of  Sternum  or  Spine 
Foreign  Body  in  Lungs 
*Gastric  Irritation 
Influenza 
Locomotor  Ataxy 
Mediastinal  Abscess 
,,  Tumour 

(Esophagismus 
Spinal  Apoplexy 
Syphilis 


111.  Praecordium 

This  is  often  hyperesthesia 
rather  than  pain. 

Anaemia 

Aneurysm 

„  of  Heart 

*Angina  Pectoris 

Aortic  Cusp,  Rupture  of 
,,      Regurgitation 

Arsenic  poisoning 

Beri-beri 
♦Endocarditis 

Epilepsy 

Fibroid  Disease  of  Heart 
♦Flatulence 

Functional  Heart  Disorder 

Gastritis 
♦Gastralgia 

Gout 
♦Heartburn  (220) 

Heartstrain 
*Hysteria 

Myocarditis,  Acute 

Pericarditis 
♦Pseudangina 

Syphilitic  Heart 


Thrombosis    of    Pulmonary 

Artery 
Valvular  Disease 

especially  aortic 

112.  Pain  in  Side 

Caries  of  Spine 

Cholecystitis 
*Faecal  Accumulation 
♦Flatulence 

Fracture  of  Spine 

pressure  of  callus  on  nerve 

Herpes  Zoster 
u  on  right  side 

Hysteria 

♦Intercostal  Rheumatism 

♦Intercostal  Neuralgia 

U     6th     to     9th    rib.      If 
bilateral,  '  girdle  pain  ' 

Pleura,  Cancer  of 

♦Pleurisy,  Acute,  i. 

♦Pneumonia,  Acute 

Pneumothorax 

onset 

Ribs,  Carious 

„      Fractured 

Spondylose  Rhizomelique 

Woillez's  Disease 


113.  Right  Hypochondrium  or 
Pain  over  the  Liver 

Abscess,  Hepatic 
,,         Perinephric 
,,         Subphrenic 
Cancer  of  Colon 

of  Duodenum 
of  Liver 
of  Pancreas 
of  Pylorus 
of  Stomach 
e  2  110-113 


52 


PAIN 


Right       Hypochondrium  — 

continued 
*Cholecystitis 
Cirrhosis  of  Liver 
Colic,  Right  Renal 
Constricted  Liver 
Cyanotic  Liver 
Distoma  Hepaticum 
Empyema  of  Gall-bladder 
^Gallstones 
Hepatitis,  Acute 
Herpes  Zoster 
Hydatids,  Inflamed 
Movable  Kidney 

Dietl's  crisis 
Neuralgia,  Intercostal 
Periarteritis  Nodosa 
Perihepatitis 
Peritonitis 
Pleurisy 
Pneumonia 
Sprain 

'  bowler's  side,'  etc. 
Syphilitic  Liver 
Ulcer,  Duodenal 
Yellow  Atrophy,  Acute 

114.  Left  Hypochrondrium 

Pain  under   the  lower  left 
ribs,  in  front. 

Abscess,  Perinephric 
„         Subphrenic 
Ansemia 

Aneurysm,  Abdominal 
Cancer  of  Colon 
splenic  flexure 
Cancer  of  Stomach 
*Colitis 
*Fsecal  Accumulation 


Gastric  Catarrh 
Gastroptosis 
Herpes  Zoster 
Malaria 

Movable  Kidney  (x) 
Neuralgia,  Intercostal 
Peritonitis 
Pleurisy 
Renal  Colic 
*Spleen,  Enlarged 
Splenic  Infarct 
Ulcer  of  Stomach 

115.  Unclassified  Chest  Pain 

Abscess,  Mediastinal 
Adiposis  Dolorosa 
Aneurysm 

„  Dissecting 

Atony  of  Stomach 
Bronchitis 
Cancer  of  Lung 
Diaphragm,  Neuralgia  of 
*Dyspepsia 
Emphysema 
Herpes  Zoster 

even  before  vesicles  appear 
MoUities  Ossium 
Myalgia 
Neurofibromata 
Phthisis,  Acute 
Pneumothorax 

onset 
Pulmonary  Embolism 
sudden 
*Rheumatism 
*Sprained  Pectorals 
Syphilitic  Periostitis 
Tumour  of  Mediastinum 


113-115 


PAIN 


53 


116.  PAIN  IN  ABDOMEN 


Pain  in  the  middle  line  points  to  the  large  intestine  if  in  the 
hypogastric  region,  the  small  intestine  if  in  the  umbilical,  and 
the  stomach  if  in  the  epigastric.  A  gastric  ulcer  is  at  the  cardiac 
end  if  the  pain  is  subxiphoid  (Mackenzie). 


117.  Epigastrium    or    Pit    of 
Stomach 

Abdominal  Angina 
Abscess,  Subphrenic 
Acute  Yellow  Atrophy 
Addison's  Disease 
Aneurysm,  Abdominal 
Appendicitis  Larvata 

not  relieved  by  vomiting 
Arsenic  -  poisoning 

*  Atony  of  Stomach 
Cancer  of  Pancreas 

„      of  Pylorus 
„      of  Stomach 
Caries  of  Spine 
Cholecystitis,  Acute 
Cholera,  Asiatic 
Cirrhosis  of  Stomach 
Dilated  Right  Ventricle 
*Dilatation  of  Stomach 
*Distended  Trans.  Colon 
Enteroptosis 
Gallstones 
'  Gout  of  Stomach  ' 
*Gastric  Irritation 
Gastralgia 

Gastro-Intestinal  Adhesions 
Gastro-cholecystic    A  d  h  e  - 

sions 
Gastritis,  Acute  Erythema- 
tous 

*  Gastritis,  Chronic 
Hepatoptosis 

Hernia,  Small  Epigastric 


*Hyperchlorhydria 

3  to  4  hours  after  a  meal 
and  continued  till  the  next 
meal  ('Hunger  Pain') 

Intercostal  Neuralgia 
Irritant-poisoning 
Liver,  Abscess  of 
,,     Cancer  of 
,.     Cyanotic 
Locomotor  Ataxy 

gastric  crisis 
Pancreas,  Cancer  of 
Pancreatic  Calculus 
Pancreatitis,  Acute 
Pericarditis  (x) 
Perihepatitis 

Pleurisy,  Diaphragmatic  (x) 
Pneumonia 

in  children 
*Strain  of  Recti  Muscles 

from  coughing  or  vomiting 
Thrombosis,  Pulmonary  (x) 
Ulcer  of  Duodenum 

2  hours  after  food 

*Ulcer  of  Stomach 

circumscribed  pain,  u  15 
minutes  after  food 

Yellow  Fever 

118.  Umbilicus 

Abscess,  Peritoneal 
Cancer  of  Colon 

„      Secondary 
Cyst,  Sebaceous 

116-118 


54 


PAIN 


Umbilicus — contin/n  d 

*Gallstones 

Gastric  Ulcer 

u    above   and    to   right  of 
navel 

*Hcrnia 
Omental  Cancer 
Oophoritis 

to  one  side  of  navel 
Spine,  Caries  of 
Recti,  Divarication  of 

119.  Hypogastrium  and  Pelvis 

Amenorrhcea 
Bladder,  Cancer  of 

,,         Distended 

,,        Tubercle  of 

,,         Ulcer  of 
Calculus 

Cancer  of  Uterus 
Chyluria 

*  Cystitis 
*Dysmenorrhcea 
♦Endometritis,  Chronic 

„  Gonorrhceal 

,,  Hemorrhagic 

„  Septic 

Fibroid,  Uterine 

Hypertrophy  of  Uterus 

Inversion  of  Uterus 

Metritis,  Acute 

Mittelschmerz 

intermenstrual,    usually 
due  to  Salpingitis 

Mollities  Ossium 
Neuralgia  of  Bladder 
„  of  Uterus 

*  Oophoritis 
Pancreatitis 
Pelvic  Abscess 

,,       Hematocele 


Pelvic  Peritonitis 
Perforation  of  Bowel 
sharp  and  sudden 

Pericystitis 
Phleboliths,  Pelvic 
*Prolapsus  Uteri 
Pyelitis 
Retroversion 
Salpingitis 
Subinvolution 
Tubal  Colic 

,,      Fcetation 
Tumour  of  Cord 

120.  Iliac  or  Ovarian 

♦Appendicitis 
right 

Caecum  Mobile 
Cancer  of  Uterus 
Cervix,  Eroded 
Colitis 

Diverticulitis 
left  iliac 

*Dysmenorrhoea 
Enteric  Fever 

right  iliac 
Floating  Rib 

pressing  on  crest  of  ileum 
*Hernia 
♦Loaded  Caecum 

right  iliac 
*Loaded  Sigmoid 

left  iliac 

Neuralgia,  Twelfth  Dorsal 
♦Neurasthenia 
Oophoritis 
Prolapsus  Uteri 
Renal  Calculus 
Retroflexion 

118-120 


PAIN 


55 


Iliac  or  Ovarian — continued 
Salpingitis 
Sigmoiditis 
Ureteral  Calculus 
Varicocele 

121.  Groin,  Pain  in 

Often  reflex 
Abscess,  Spinal 
Calculus 

Cancer  of  Rectum 
Corn,  Inflamed 
Haemorrhoids 
*Hernia,  Inguinal 
„        Obturator 
„        Umbilical 
Meckel's  Diverticulitis 
*Ovary,  Prolapsed 
Polypus,  Rectal 
Rider's  Sprain 
Saphenous  Varix 
Talipes  Valgus 
Tibia,  Old  Fracture  of 

,,       Osteoma  of 
Testicular  Cysts 
*Varicocele 

122.  Colic 

Including  gastric  crises. 

Abortion 

Appendicular  Colic 

Cancer  of  Bowel 

Colitis 

Diarrhoea 

Dysentery 

Food-poisoning 

Foreign  Body  in  Bowel 

Gallstones 

Henoch's  Purpura 

Hernia,  Strangulated 

Hydronephrosis 


Influenza 

Intestinal  Concretion 
Intussusception 
Lead-poisoning 
Locomotor  Ataxy 
Neuralgia,  Intestinal 
Ovarian  Cyst 
twisted  pedicle 

Pancreatic  Calculus 
Peritonseal  Adhesions 
Pyloric  Stenosis 
Renal  Calculus 
Rheumatism,  Intestinal 
Scybala 

Uterine  Fibroid 
Ureteral  Calculus 

123.  Unclassified   Abdominal 
Pain 

Abscess,  Subphrenic 

Achylia  Gastrica 

Aneurysm,  Abdominal 

Aortic  Regurgitation 

Cancer 

Caries,  Spinal 

Cholera 
*Colic 

Colitis 
*Diarrhcea 
*Dyspepsia 

Ectopic  Gestation 

Embolism  of  Sup.  Mesenteric 

Enteritis 

Enteroptosis 

Enterospasm 
*Faecal  Accumulation 

Foreign  Body 
*Gallstones 
*Gastralgia 

Glands,  Inflamed 

Glandular  Fever  • 

120-123 


56 


PAIN 


Unclassified        Abdominal 
Pain — continued 
Henoch's  Purpura 
gastric  crisis 

*Hernia 

„      Diaphragmatic 

Herpes  Zoster 

Hydronephrosis  (when  large) 

Hysteria 

Ileus 
*Influenza  (gastric  form) 

Intestinal  Concretion 
„         Obstruction 

Intussusception 

Irritant-poisoning 

Kidney,  Tuberculous 
*Lead  CoHc 

Leukaemia 

Locomotor  Ataxy 
gastric  crisis 

Lymphadenoma 

Meningitis,  Spinal 

Mesenteric  Cysts 

Myalgia 

Neuralgia,      Lumbo  -  abdo  - 

minal 
^Neurasthenia 

Ovarian  Cyst 

Pancreatic  Disease 

Perforation 

Periarteritis  Nodosa 

Pericarditis  (x) 

Peritonitis 

Pernicious  Anaemia 

Pleurisy,  Diaphragmatic 
„         Incipient  (x) 

Pneumonia 
in  children 

Pneumothorax  (x) 

Polycythemia,      Splenome- 
galic 


Ptomainism 
Rheumatic  Fever 
Rheumatism 
Spinal  Tumour 
Tabes  mesenterica 
Thrombosis,  Mesenteric 
Ulcer  of  Intestine 

Hypochondria  (see  Chest,  113, 
114) 

124.  Perinaeum 

*  Abscess,  Ischio-rectal 
,,         Perinaeal 
,,         Prostatic 
Bartholinitis 
Bladder,  Tuberculosis  of 
Cancer  of  Bladder,  Prostate 

or  Rectum 
Calculus,    Vesical    or    Pros- 
tatic 
Condylomata 
Cystitis 
Cystocele 

Epithelioma,  Vaginal 
Extravasation  of  Urine 
*Fissure  of  Anus 
*Fistula 
*Hsemorrhoids 
Locomotor  Ataxy 
rectal  crisis 

Mania 

Prostate,  Adenomatous 

,,         Tuberculous 
*Prostatitis 
Rectum,  Ulcer  of 
Seminal  Vesiculitis 
Testicle,  Perinaeal 
Uterine  Disease 
Vaginitis,  Acute 
(see  Painful  Defalcation,  1082) 
123-124 


PAIN 


57 


125.  Rectum 

Abscess,  Ischio -rectal 

„         Prostatic 
Cancer  of  Bladder,  Prostate 

Rectum,  or  Uterus 
Colitis,  Membranous 
Condylomata 
Cystitis 
Dysentery 

burning 
Fissure  of  Anus 
Fistula 

Faeces,  Impacted 
Foreign  Body 
Haemorrhoids 
Locomotor  Ataxy 

rectal  crisis 
Neuralgia,  Rectal 
Perimetritis 
Salpingitis 
Ulcer,  Rectal 
Vesiculitis,  Seminal 

126.  Penis 

Bladder,  Cancer  of 

peduncular 
Bladder,  Tuberculous 

glans 
Bladder,  Ulcer  of 

„         Villous  growth  of 
Calculus,  Ureteral 
„         Urethral 
,,         Vesical 
in  glans 
Cystitis 

Fissure  of  Anus  (x) 
*Gravel 
Neuralgia 


Prostate,  Abscess  of 
„  Adenomatous 

„         Cancer  of 
„         Tuberculous 
Renal  Colic  (x) 
Stone  in  Ureter 
*Stricture 
Urethral  Granulations 
Venery,  Excessive 
***  Also  too  acid  urine. 

(See  Painful  Micturition. 
941) 

127.  Testicle 

Abdominal  Aneurysm 
,,         Tumour 

Calculus,  Renal 
„         Vesical 

Cancer 

Caries,  Lumbar 

Colon,  Tumour  of 

Cysts 

Embryoma 
*Epididymitis 

Gumma 

Hernia 

Hsematocele 

Hydrocele  (x) 

,,         Encysted 
*Injury 
^Neuralgia 

Nodules  in  Epididymis 
*Orchitis 

Sarcoma 

Torsion  of  Cord 

Tuberculous  Testis 
*Varicocele 

Venery,  Excessive 


125-127 


58 


PAIN 


PAIN 

128.  Shoulder 
Aneurysm  of  Innominate 
Angina  Pectoris 

u  left  shoulder 
Aortic  Disease 
right  shoulder 
*Atony  of  Stomach 
Cancer  of  Liver 

angle  of  right  scapula 
♦Cervico-brachial  Neuralgia 
♦Colitis 

Dental  Caries  (x) 
Diaphragmatic  Pleurisy 
Duodenal  Catarrh 

,,         Ulcer 
*Fibrositis 
Hepatic  Abscess 
„        Colic 
right  shoulder 
Hepatic  Congestion 
Hepatitis,  Acute 
Mediastinal  Tumour 
*Neuritis 
Pleurisy,  Acute  (x) 
Pneumonia  (x) 
Progressive  Muscular  Atro- 
phy, I. 
♦Rheumatism 
Serratus  Palsy 
♦Synovitis  (see  Joints,  139) 
Tumour  of  Suprarenal  Cap- 
sule 
tip  of  shoulder-blade 

129.  Arm 

Adiposis  Dolorosa 
Amyotrophic  Lat.  Sclerosis 
Aneurysm,  Subclavian 
♦Angina  Pectoris 
uleft 
Atonic  Dyspepsia 


IN    LIMBS 

Brachial  Neuralgia 
♦Brachial  Neuritis 
Caries,  Cervical 
Cervical  Rib 
♦Cervico-brachial  Neuralgia 
♦Fibrositis 
Morvans  Disease 
Neurasthenia,  Traumatic 
course     of     musculo-spiral 
nerve 
Neuroma 
♦Occupation  Neurosis  (27) 
Pachymeningitis,  Cervical 
Paralysis  agitans 
Progressive  Muscular  Atro- 
phy 
♦Rheumatism 
Syringomyelia 
Tumour,  Spinal 
Valvular  Disease  (x) 
(See  Limbs,  138) 

130.  Hand 

Acroparsesthesi  a 

Chondroma 
♦Gout 

Neuritis 

Neuroma 
♦Occupation  Neurosis  (27) 

Raynaud's  Disease 

Rheumatism 
♦Rheumatoid  Arthritis 

Teno-synovitis 
♦Trauma 

Tubercle 

131.  Thigh 

Abdominal  Tumour 
Aneurysm,  Abdominal 

radiating 
Aneurysm,  Femoral  or  Pop- 
liteal 

128-131 


PAIN 


59 


Thigh — continued 

Cancer  of  Rectum 

Caries,  Lumbo-Sacral 

Colon,  Growth  on 

Dysmenorrhea 
*Fibrositis 

Hip  Disease 

Hysteria 
*Impactecl  Faeces 

Infantile  Scurvy 

Locomotor  Ataxy 

Lumbar  Abscess 

Meningitis,  Spinal 

Meralgia  Paraesthetica 

Metritis 
*Neuralgia,  Ant.  Crural 
„  Obturator 

Neurasthenia 
*Neuritis 

Neuroma 

Ovarian  Cyst 

Pelvic  Cellulitis 
,,      Tumours 

Perimetritis 

Periostitis,  Femoral 

Pregnancy 

Psoas  Abscess 

Renal  Calculus 

Sacral  Glands,  Enlarged 

Sarcoma  of  Femur 
,,         of  Innominate 
*Sciatica 

Uterine  Displacement 

Vesical  Calculus 


132.  Howship-Romberg  Sign 

Numbness   or   pain  on   the 
inner  side  of  the  thigh. 

Obturator  Hernia 
,,  Neuralgia 


133.  Leg 

Claudication  Intermittente 
Friedreich's  Disease 
Infantile  Paralysis 
onset 

Lead-poisoning 

Leukaemia 
*Neuralgia,  Ant.  Crural 
inner  side 

Neuralgia.  Ext.  Cutaneous 

Osteomyelitis 

Periostitis 
*Phlebitis 

Phlegmasia  Alba  Dolens 

Primary  Spastic  Paraplegia 
*Rheumatism 

Sciatica 

Spinal  Meningitis 

Tuberculous  Bone 

134.  Foot 

*Callosities 
*  Corns,  etc. 

Erythromelalgia 
*Flat  Foot 
*Gout 

Locomotor  Ataxy 

Metatarsalgia 

Movable  Kidney 

Nail,  Ingrowing 

Neurasthenia 

Ovarian  Diseases 
sole 

Periostitis 

Plantar  Neuralgia 

Prostatic  Disease 
sole 

Raynaud's  Disease 

Renal  Calculus 
*Rheumatism 

Trauma 

Tuberculous  Bone 

131-134 


60 


PAIN 


135.  Heel 

Sprain 

Arthritis,  Gonorrhoeal 

Syphilis 

Calcanodynia 

Trichinosis 

*Gout 

Tuberculous  Meningitis,  I. 

Lithaemia 

Weil's  Disease 

Neurasthenia 

calves 

Muscular  pain  is  also  com- 

136. Heel-jar 

mon  after  unaccustomed 
exertion,  and  when  owing 

The  patient,  standing  on  tip- 

to some  disablement,  mus- 

toe, experiences  a  spinal 

cular     movements     have 

pain  on  bringing  the  heels 

ceased   to  be  automatic. 

suddenly  to  the  ground. 

(See  General  Pain  87) 

Spinal  Caries 

***  A    similar    pain,    but    felt 

138.  Limbs,  Pain  in  (Unclassi- 

in one  loin,  is  produced 

fied) 

One  or  both. 

by  renal  calculus,  and  in 
one  hip,  by  hip  disease. 

Abdominal  Tumours 

137.  Muscles  (Myalgia) 

Adhesions,  Peritonaeal 

♦Alcoholism 

Ague  (praem.) 

Anaemia 

Appendicitis 

Biliary  Congestion 

Beri-beri 

Cerebro-spinal  Meningitis 

Caisson  Disease 

Cholera 

Cancer  of  Rectum 

Coryza 

simulating  sciatica 

Duodenal  Catarrh 

Cancer  of  Bone 

Enteric  Fever 

Cauda  Equina,  Tumour  of 

*Fibrositis 

Compression  of  Cord 

♦Illness,  Acute 

Dengue 

onset  and  convalescence 

Diabetes 

♦Influenza 

sometimes  '  lightning  ' 

♦Invasion    Stage    of    Exan- 

Erythromelalgia 

themata      and      Visceral 

of  the  swellings 

Inflammations 

Exostosis 

Locomotor  Ataxy 

Fevers 

Milroy's  Disease 

invasion  stage 

crisis 

General  Paralysis,  I. 

♦Muscular  Rheumatism 

Glanders 

♦Occupation  Neurosis  (27) 

Haemophilia 

Psittacosis 

Hysteria 

Relapsing  Fever 

Impacted  Embolism 

Rheumatic  Fever,  I. 

*Iniluenza 

*Scurvy 

Kidney,  Floating 

Septicaemia 

135-138 

PAIN 


61 


Limbs,  Pain  in — continued 
Kink,  Ileal 
Lead-poisoning  (x) 
Lipomatosis  Neurotica 

in  the  fatty  patches 
Locomotor  Ataxy 

'  lightning  '    or  rheumatoid 
Mollities  Ossium 
*Multiple  Neuritis 
Muscle,  Rupture  of 

e.g.  plantar  is 

Myalgia  (137) 

Myelitis 

Myelosarcoma 

Myositis 

Neurasthenia 
*Occupation  Neurosis 

Oophoritis 

Osteitis 

Paralysis  Agitans 

Periarteritis  Nodosa 

Periostitis 

Phthisis,  Advanced 

Plague 

Progressive  Muscular 
Atrophy 

Remittent  Fever 
*Rheumatism 
*Rickets 

Softening,  Chronic 

Spinal  Apoplexy 
,,      Meningitis 

Strains 

Syphilis 

Tetanus 

Thrombosis 

Tonsillitis,  Follicular 

Trichinosis 

Tuberculous  Bone 
*Urticaria 

Uterus,  Cancer  of  (x) 

Wasting^Diseases  (311) 


139.  Joints 

Arthritis,  Gonorrhceal 
,,  Pneumococcal 

„  Post-febrile 

,,  Rheumatoid 

Caisson  Disease 
Cartilage,  Displaced 
Chorea  (x) 
Compression  of  Cord 
Coxa  Vara 

sometimes  begins  in  knee 
*Fibrositis 
Glanders 
*Gout 
'  Growth  Fever ' 

epiphyses 
Gums,  Septic 
*Hip  Disease 
knee  first 

Hydrarthrosis,  Intermittent 
'  Hysterical  Joint ' 
Infantile  Paralysis 
onset 

*Injuries 
Lead-poisoning 
Locomotor  Ataxy 
Loose  Cartilage 
Malta  Fever 
Myelitis,  Acute 
Myelosarcoma 
Neuralgia 
Obturator  Hernia 
knee 

Peliosis  Rheumatica 

Phthisis,  Advanced 

Pyaemia 

Recklinghausen's  Disease 
*Rheumatism,  Acute 
*Rheumatism,  Chronic 

Rickets 

138-139 


62 


PAIN 


Join  ts — continued 
Scurvy 
*Synovitis 


Syphilis 
Syringomyelia 
Tuberculous  Joint 


140.  CHARACTER  OF  PAIN 

The  personal   equation   must  be   allowed  for. 
sensitive  to  the  sesthosiometer  than  are  women. 


Men  are   more 


141.  Sharp 

Acute  Inflammation  of  Ser- 
ous or  Synovial  Mem- 
branes in  general 

Angina  Pectoris 

Appendicitis 

Dissecting  Aneurysm 

Ectopic  Gestation 

Fractures 

Gout 

Neuritis 

Pleurisy,  Acute 

Pneumothorax 
onset 

Spinal  Meningeal  Haemor- 
rhage 

142.  Dull 

Chronic  Inflammation  of 
Serous  Membranes 

Inflammation  of  Mucous 
Membranes  and  of  Visceral 
Parenchyma 

143.  Paroxysmal 

Aneurysm 
Angina,  Abdominal 
,,       (Esophageal 
*Angina  Pectoris 
Appendicitis 
*  Appendicular  Colic 
temperature  normal 

Calculus  of  Pancreas 
Cancer  of  Pancreas 


Cancer  of  (Esophagus 

Cerebral  Tumours 
*Clot  in  Ureter 

Colitis 
*Colic  (122) 

relieved  by  pressure 

Diabetes  (x) 

Disseminated  Sclerosis 
*Distended  Bladder 

Dysentery 

Dysmenorrhcea 

Erythromelalgia 
*Floating  Kidney 

Dietl's  crisis 
*Gallstone  Colic 

Heart,  Syphilitic 

Henoch's  Purpura 
abdominal  crisis 

Hepatic  Aneurysm 

Hernia 

Hydatids  of  Kidney 

daughter  cysts  in  ureter  or 
gall -duct 

Intussusception 

*Lead  Colic 

Locomotor  Ataxy 

gastric,  nephralgic,  or  other 
crisis 

Lumbrici 
Mercurialism 
Neuralgia 
Ovarian  Cyst 
twisted  pedicle 

139-143 


PAIX 


63 


Paroxysmal — continued 

Parturition 

Pulpitis,  Dental 

Pyloric  Ulcer 
♦Renal  Calculus 

Scybala  or  Concretions 

Spinal  Meningitis 

Sporadic  Cholera 
*Tic-douloureux 

Tubal  Colic 

Tuberculous  Synovitis 

Ureteral  Calculus 
♦Urethral       „ 

Vesical  „ 

Uterine  Cancer 
„         Fibroids 
Polypus 


144.  Radiating 

Abdominal  Aneurysm 

back,  false  ribs,  groin,  and 
testes 

Acute  Aortitis 

arm 
Aneurysm  of  Asc.  Aorta 

back,   shoulders,   and  arms 

Aneurysm  of  Innominate 
right  shoulder 

Angina,  Abdominal 

Angina  Pectoris 

left  arm  and  shoulder    and 
up  neck  to  forehead 

Aortic  Regurgitation 
arm  and  back 

Atony  of  Stomach 

shoulder 
Caries  of  Spine 

sternum,     epigastrium,     or 
abdomen 


Cerebellar  Tumours 

nucha  and  between  scapulae 
Cervical  Rib 

shoulder,  elbow,  fingers 
Compression  of  Cord 
Gastritis,  Acute  Erythema- 
tous 

shoulder  and  left  arm 
Hepatic  Colic 

around  umbilicus 
Hip  Disease 

knee 
Liver  Affections 

shoulder 
Xeuralgia 

nerve-terminations 
Oophoritis 

back  and  limbs 
Otitis  Media.  Acute 

occiput,  vertex,  and  temple 
Pachymeningitis,     External 

Spinal 
Pancreatic  Calculus 
Pelvic  Abscess 

thighs 

Pulmonary  Abscess 

to  larynx  (on  percussion  of 
chest) 

Rectum,  Cancer  of 

limbs 

Renal  Calculus 

thigh  and  testicle  ;  some- 
times referred  to  opposite 
kidney 

Spinal  Tumour 
nerve- endings 

Spinal    Meningeal    Haemor- 
rhage 
nerve-endings 

Spinal  Meningitis,  Internal 
143-144 


04 


PAIN 


Radiating — continued 
Spleen  Affections 

left  shoulder 
Uterine  Fibroids 
genitals  and  legs 
Vesical  Calculus 

meatus        urinarius        and 
testicle 

145.  Shifting  Pain 
*Flatulence 
Gout 
Hysteria 

Locomotor  Ataxy 
Neuralgia 
Rheumatism 
Spinal  Tumour 
Tapeworm 
Trichinosis 


146.  Gnawing  or  Boring  Pain 

*  Abdominal  Aneurysm 
in  back 

Cancer  of  Stomach 
*Caries  of  Spine 
descending  Thoracic  Aneu- 
rysm 

Gout 

Lithsemia 

Mediastinal  Growth 

Periostitis 

Spinal  Meningitis 

147.  Increased  by  Food 

Arsenic  -poisoning 

Cancer  of  Stomach 
„      of  Duodenum 
„      of  (Esophagus 

Gastritis 


Renal  Calculus 

largo  stono  on  left  side 
Ulcer  of  Duodenum 

2  hours  after  food 
Ulcer  of  Stomach 

£  hour  after  food 

148.  Relieved  by  Food 
'  Hunger  Pain  ' 

Appendicitis 
Cholecystitis,  Chronic 
Gastralgia 
Hyperchlorhydria 
Ulcer,  Duodenal 

149.  Relieved  by  Pressure 

If  firm,  flat,  and  gradual. 
Colic,  Abdominal  (122) 
Lumbago 
Pleurodynia 
Pleurisy 

Muscle,  Ruptured 
Rib,  Fractured 

150.  Increased    by    Movement 

Adhesions  where  one  organ 
is  fixed. 

Abscess,  Local 
,,  Pelvic 

Acute     Inflammatory    Dis- 
eases 
Appendicitis  Larvata 

brought  on  by  exercise 
Arthritis 
*Caries  of  Spine 
Cartilage,  Displaced 
Coxa  vara 
Faecal  Accumulation 
on  running  fast 

144-150 


PAIN 


Increased  by  Movement — 
continued 
Fibrositis 
Fractures 
Glandular  Fever 
Gout 
Hernia,  Obturator 

by  hip  movement 

*Lumbago 

Myositis 

Neuritis 

Oophoritis 

Ovarian  Pedicle,  Twisted 

Pachymeningitis,  External 
Spinal 

Pelvic  Cellulitis 

Perinephritis 

Peritonitis 

Pleurisy,  Acute 

Pleurodynia 

Pneumonia,  Acute 
*Renal  Calculus 

esp.  on  stamping 

Rheumatism,  Acute 

,,  Muscular 

Rheumatoid  Arthritis 
*Ruptured  Muscle 

contraction  of  opponent 

Salpingitis 
Sciatica 

Spinal  Column,  Sprain  of 
on  rotation 

Spinal  Meningitis 

Spondylitis,  Traumatic 
*Sprains 
^Synovitis 

Tuberculous  Joint 

Tumour,  Cranial 
,,         Intracranial 


Tumour,  Spinal 
Vesical  Calculus 
Weil's  Disease 


151.  Increased  by  Breathing  or 
Coughing 

Caries  of  Sternum 

Cholecystitis 

Diaphragmatic  Hernia 
„  Pleurisy 

Fractured  Ribs 
*Intercostal  Rheumatism 

Perforation  of  Stomach 

Perihepatitis 

Perinephritis 

Peritonitis 
*Pleurisy 

Pneumothorax 

Subphrenic  Abscess 

Trichinosis 


152.  Increased  at  Night 

Most     pain     is     so,     but 
especially  that  from — 

Arthritis,  Gonorrhoeal 
Carcinoma 
Erythromelalgia 
Locomotor  Ataxy 
Neuritis 
Otitis  Media 
Osteitis 
Periostitis 
Renal  Calculus 
Rheumatism 
Syphilis 

Tuberculous  Joint 

Ulcer  of  Stomach 

when  adherent 

150-152 


66 


PAIN 


153.  Referred  Pain 

A  pain  which,  though  re 
f erred  to  the  skin,  origin- 
ates in  a  neighbouring 
viscus.  It  bears  no  rela- 
tion to  nerve  distribution. 
(See  325.) 

Angina  Pectoris 
arm 

Dysmenorrhea 
thigh 


Heart  Disease 

arm 
Liver  Affections 

shoulder 
Ovarian  Disease 

mamma 
Renal  Colic 

testicle 


153 


TENDERNESS 


67 


154.  TENDERNESS 

This  is  often  untruthfully  affirmed,  especially  when  a  claim 
for  compensation  is  made.  The  patient  should  not  be  asked 
if  pressure  give  pain  ;  but  in  the  midst  of  conversation,  the 
part  should  be  pressed,  at  first  very  gently  and  afterwards 
with  the  force  gradually  increased,  and  if  genuine,  the  pulse 
rate  will  go  up  (Mannkopf's  sign).  The  countenance,  too, 
should  be  watched  all  the  time,  and  it  will  probably  speak 
more  truthfully  than  the  tongue.  Cutaneous  hyperesthesia 
may  be  distinguished  from  tenderness  by  the  pain  being  still 
complained  of  when  the  skin  is  lightly  pinched  without  any 
pressure  on  subjacent  parts. 

The  pain  of  all  inflammatory  affections  is  accompanied 
by  more  or  less  tenderness. 


155.  Scalp 

Cerebral  Tumour 

over  site 
*Clavus  Hystericus 

Erysipelas 

Gumma 

Herpes 

Hydrocephalus 

Lupus  Erythematosus 

Mastoid  Abscess 

Meningitis 

Migraine 

Neuralgia,  Cervico-occipital 
*Neurasthenia 

Otitis  Media 

Recklinghausen's  D  sease 

Rheumatism 

Rickets 

Sclerodermia 
*Seborrhsea,  Acute 

Syphilis,  Congenital 

Syphilitic  Periostitis 

Thrombosis  of  Lateral  Sinus 
behind  ear 

Trauma 

Trigeminal  Neuralgia 


156.  Spine 

The    spinous     processes 
should  be  percussed. 

Abscess,  Lumbar 
„         Mediastinal 
„  Perinephric 

,,  Post  Pharyngeal 

„         Subphrenic 
Aneurysm,  Abdominal 

,,  of  Desc.  Aorta 

Arthritis,  Rheumatoid 
Cancer  of  Spine 
Caries  of  Spine 

„      Sicca 
Compression  of  Cord 
*Gastritis 

4th  to  7th  dorsal 
Glands,  Enlarged  Bronchial 

4th  and  5th  dorsal 
Heart  Disease 

upper  dorsal 

Hepatic  Colic 
6tb  to  9th  dorsal 
*Hysteria 
2  154-156 


68 


TENDERNESS 


Spike —  continued 
Liver  Diseases 
lower  dorsal 

Mediastinal  Tumour 
Meningitis,  Cerebro-spinal 

„  Spinal 

Myelitis,  Chronic 

not  increased  by  movement 

♦Neurasthenia 
Neurasthenia,  Traumatic 

esp.  1st,  6th,  7th,  12th  dor- 
sal, 1st  sacral  and  coccyx 

Rickets 

Spinal  Apoplexy 
„      Periostitis 
Spondylitis,  Traumatic 

on  stooping  or  rotation 
Sppndylose  Rhizomelique 
Tumours  of  Spine 
Typhoid  Spine 
Ulcer  of  Duodenum 

right  of  12th  dorsal 

Ulcer  of  Stomach 

to  left  of  12th  dorsal  and  on 
percussion  of  4th,  5th,  6th, 
7th,  dorsal  spines,when  on 
lesser  curvature;  of  10th, 
11th,  12  th  dorsal,  when  on 
greater  curvature  ;  and  of 
8th,  9th,  10thdorsal,when 
the  ulcer  is  on  the  side 
of  the  organ 


157.  Lumbar   Tenderness 

Appendicitis 

right  side 
*Lumbar  Abscess 
Nephritis,  Acute 

„         Suppurative 
Perinephric  Abscess 


♦Perinephritis 
Renal  Calculus 
,,      Cancer 
,,      Infarct 

158.  Chest 
Abscess,  Hepatic 
Aneurysmal  Prominence 
*Angina  Pectoris 
Bronchitis,  Acute,  I. 
Caries  of  Sternum 
Diaphragmatic  Neuralgia 
zonal 

Empyema  necessitatis 
Heart  Strain 
Herpes  Zoster 
Hysteria 
♦Intercostal  Neuralgia 

„  Rheumatism 

Mediastinal  Disease 
Myocarditis 
Pericarditis 
Periostitis,  Costal 

,,  Sternal 

Phthisis 

on  percussion 
Pleurisy,  Acute 

interspaces 
Pleurisy,  Diaphragmatic 


159.  Mamma  or  Breast 

Abscess 

Hysteria 

Mastitis 

Menstruation 

Oophoritis 

Pregnancy 

Also  in  cancer,  cysts,   and 
tumours  when  inflamed. 

156-159 


TENDERNESS 


69 


160.  Right  Hypochondrium 

Including  Liver  Tenderness. 

Abscess  of  Liver 

Actinomycosis 

Acute  Yellow  Atrophy 

Asthma 

Cancer  of  Liver 

Cirrhosis   of   Liver,    Hyper- 
trophic 
♦Cyanotic  Liver 

Empyema  of  Gall-bladder 

Fatty  Degeneration  of  Liver 
♦Gallstones 

Hepatitis,  Acute 

Hydatids,  Inflamed 

Influenza 

Jaundice,  Obstructive  (392) 

Malaria 

Myocarditis 

Perihepatitis 


Relapsing  Fever 
Sarcoma  of  Liver 
Syphilitic  Liver 
Weil's  Disease 

161.  Left  Hypochondrium 
Including  tender  spleen. 

Anaemia,  Splenic  (x) 
Enteric  Fever 
♦Impacted  Faeces 
splenic  flexure 
Influenza 
Leukaemia,   Spleno-medul- 

lary 
Malaria 
Perisplenitis 
Relapsing  Fever 
Spleen,  Abscess  of 
„       Cancer  of 
„       Infarct  of 


162.  ABDOMINAL  TENDERNESS 

Firm  and  steady  pressure  relieves  reflex  abdominal  tenderness, 
but  aggravates  tenderness  due  to  inflammation. 


163.  Epigastrium 

Acute  Yellow  Atrophy 
Addison's  Disease 
Appendicitis  Larvata 
Arsenic-poisoning 
Cancer  of  Stomach 

moderate 
Cirrhosis  of  Stomach 

slight 

Dilated  Right  Ventricle 
Gallstones 

Gastritis,  Acute    Erythema- 
tous 
♦Gastritis,  Chronic 


Hypochondriasis 

Hysteria 

Irritant-poisoning 

Liver  Tenderness  (160) 

Pancreas,  Inflammation  of 

Pericarditis,  Acute 
♦Peritonitis 

Pleurisy,  Diaphragmatic 
♦Ulcer  of  Stomach 

acute  ;  small  circumscribed 
area.  Similar  area  in 
back 
4s*  Epigastric  tenderness  often 
follows  severe  coughing 
or  vomiting. 

160-163 


70 


TENDERNESS 


164.  Iliac 

Abscess      of      Abdominal 

Wall 
Alcoholism 
Appendicitis 
right  side 

Caecum  Mobile 
Calculus,  Renal 

„         Ureteral 
Cancer  of  Caecum 
„      of  Uterus 
Cervix,  Eroded 
♦Dysmenorrhcea 
Enteric  Fever 

right  side — gurgling 

Faecal  Accumulation 
Hysteria 

Neuralgia  of  12  Dorsal  N. 
♦Oophoritis 
Pelvic  Cellulitis 

,,      Peritonitis 
Pneumoperitoneum 
Prolapsus  Uteri 
Psoas  Abscess 
Retroflexion 
Sacro-iliac  Disease 
Salpingitis 
Sigmoiditis 
Tubal  Gestation 

rupture 
Tubercle  of  Caecum 
Uterine  Congestion 


165.  Erichsen's  Sign 

Compression  inwards  of  the 
two  iliac  bones  causes 
pain  in 

Sacro-iliac  Disease 

but  not  in  hip  disease 


166.  Hypogastrium 
Bladder,  Ulcer  of 
Calculus,  Vesical 

♦Cystitis 
Dysmenorrhcea 

♦Metritis,  Acute 
Pelvic  Peritonitis 
Pericystitis 

♦Perimetritis 


167.  Perinaeum,  Tender 

♦Abscess,  Ischio -rectal 
„        Prostatic 
„         Urethral 
Haemorrhoids,  Inflamed 
Proctitis 

Prostate,  Cancer  of 
♦Prostatitis 


168.  Unclassified   Abdominal 
Tenderness 

Cancer  of  Intestine 
Colitis 

Diaphragmatic  Pleurisy 
Dysentery 
Dysmenorrhcea 
Fibrositis  of  Abdominal 
Muscles 

only  when  contracted 
♦Gallstones 

1  in.  to  right  of  and  above 
umbilicus 

Irritant-poisoning 
♦Peritonitis,  Acute 
♦Sequela  of  Colic 

Strangulated  Hernia 

unless  gangrenous 
Ulceration  of  Intestine 
164-168 


TENDERNESS 


71 


169.  Limbs,  Tenderness  of 

Bone,  Cancer  of 
Epiphysitis,  Syphilitic 
♦Erythema  Nodosum 
Erythromelalgia 
Gout 

'  Growth  Fever ' 
Hip  Disease 

pain   in    knee    on    tapping 
trochanter 

♦Infantile  Scurvy 
lower  end  of  thighs 

Leukaemia 

Myostitis 
♦Neuritis 
♦Neuritis,  Multiple 

Osteitis 

Periostitis 
♦Phlebitis 

a  long  hard  vein 

Phlegmasia  Alba  Dolens 
usually  left  leg 

Polymyositis 
♦Rickets,  I. 
Schlatter's  Disease 

tibial  tuberosity 
Scurvy 


Spinal  Meningitis,  Int. 

Tetanus 

Trichinosis 

170.  Feet,  Tender 
Callosities 
Chilblains 
Corns 

Gout 

Metatarsalgia 
Talipes  Valgus 
Toenail,  Ingrowing 

171.  Joints,  Tender 

♦Gout 

Hysterical  Joint 

Loose  Cartilage 

Malta  Fever 
50  per  cent. 

Myelosarcoma 

Pyaemia 

♦Rheumatism,  Acute 
♦Rheumatoid  Arthritis 

Spondylose,  Rhizomelique 
shoulders,  hip,  and  spine 
♦Sprain 
♦Synovitis 

Tuberculous  Arthritis 


172.  TENDER  SPOTS 


173.  Clavus  Hystericus 

Near  parietal  prominence. 
Hysteria 

174.  Signorelli's  Sign 

Between  the  jaw  and  the 

mastoid  process  and  below 
the  ear. 


Meningitis 

Said     to     be     earlier 
Kernig's  Sign. 


than 


175.  Francke's  Sign 

Deep  tenderness  over  apex 
of  lung  behind. 

Early  Phthisis 
81%  of  cases 


176.  Ninth  Right 
tilage 

Cholecystitis 
Enteric  Fever 
early 


Costal  Car- 


169-176 


72 


TENDER  SPOTS 


Ninth  Right  Costal  Carti- 
lage — continued 
Gall-bladder,  Calculus  in 
,,  Cancer  of 

,,  Empyema  of 

177.  Babe's  Sign 

Tenderness  over  splenic 
artery,  accompanied  by 
muscular  rigidity. 

Aneurysm    of    Abdominal 
Aorta 

178.  Mendel's  Sign 

A  tender  area,  the  size  of 
a  florin,  elicited  by  light 
percussion  in  the  epigas- 
trium. 

Duodenal  Ulcer 
Gastric  Ulcer 

179.  Mussy's  Point 

A  tender  spot  where  the 
left  sternal  line  extended 
downwards  intersects  a 
horizontal  line  on  the 
level  of  the  tenth  ribs. 
(S  10,  in  chart.) 

Diaphragmatic  Pleurisy 

180.  McBurney's  Point 

Midway  between  umbilicus 
and  anterior  superior  spine 
of  right  ilium. 
Munro's   Point,   instead   of 
being  midway,  is  at  the 
outer  edge  of  the  rectus. 
It    is    said    to    be    more 
exactly  over  the  ileocecal 
valve. 
*Appendicitis 
Lead-poisoning  (x) 
Ureteral  Calculus 


181.  Bastedo's  Test 

Pain  at  McBurney's  Point 
produced  by  inflation  of 
the  colon. 

Appendicitis 

The  test  is  not  always  safe 
in  acute  cases. 

182.  Blumberg's  Sign 

Pressure  over  the  descending 
colon  produces  pain  in  the 
right  iliac  fossa. 

Appendicitis 

183.  Bittorf's  Sign 

On  squeezing  the  testicle 
or  pressing  on  the  ovary 
during  an  attack  of  colic 
the  pain  radiates  to  the 
kidney  in 

Renal  Calculus 

184.  Douleur  Signal  (Leven) 

Abdominal  pain  ceases  when 
the  stomach  is  forced 
upwards  by  deep  pressure 
in  the  hypogastric  region. 

Dilatation  of  Stomach 

Thus  differentiating  it  from 
Appendicitis. 

185.  Kink  Sign 

Tenderness  on  a  line  drawn 
between  the  umbilicus 
and  the  middle  of  Pou- 
part's  ligament. 

Ileal  Kink 


185.  Boas'  Point 

to     left     of     12th 
vertebra 

Gastric  Ulcer 


dorsal 


176-186 


TENDERNESS 


73 


187.  POINTS  DOULOUREUX 

Often  absent  in  first  attacks. 


Trigeminal  Neuralgia 

1st  division. — Supra-orbital 
notch,  above  parietal 
eminence,  and  junction  of 
nasal  bone  with  nasal 
cartilage 
2nd  division. — Infra-orbital 
foramen,  malar  bone,  gum 
of  upper  jaw 
3rd  division. — Temple,  in 
front  of  ear,  mental  fora- 
men and  side  of  tongue 

Cervico- occipital  Neuralgia 

midway  between  the  mas- 
toid process  and  the  1st 
cervical  vertebra 

Cervico-brachial  Neuralgia 
axilla,  upper  part  of  deltoid, 
bend  of  elbow  and  behind 
inner  condyle 


Intercostal  Neuralgia 

spinous  process,  side  of 
chest  or  abdomen,  and 
a  point  just  short  of  the 
mesial  line 

Twelfth  Dorsal  Neuralgia 

Edge  of  quadratus  lum- 
borum,  ant.  sup.  spine, 
and  near  symphysis  pubis. 

Lumbo  -  abdominal       Neu- 
ralgia 

spinous  process,  midcrest 
of  ilium,  hypogastrium, 
groin,  and  scrotum 

Sciatica 

posterior  iliac  spine,  sciatic 
notch,  and  behind  knee, 
head  of  fibula,  and  ex- 
ternal malleolus 


187 


74 


ALGESIC 


188.  ALGESIC 

Analgesia  duo  to  a  cord  lesion  is  both  deop  and  superficial ; 
but  in  that  produced  by  a  peripheral  nerve  lesion,  the  superficial 
analgesia  may  be  combined  with  deep  hyperalgesia. 


189.  Analgesia  (Insensibility  to 

pain) 

It    is    usually    tested    with 
pin-pricks. 

Arsenic -poisoning 
Brown-Sequard's  Paralysis 
Catalepsy,  Severe 
Diphtheritic  Paralysis 
General  Paralysis  of  Insane, 

ii. 
Hsematomyelia 
Hemiplegia 
*Hysteria 

often  hemianalgesia 
*Hystero -epilepsy 
Insanity 

sometimes  cubital 
*Locomotor  Ataxy 

A  zone  on  the  trunk  from 
the  2nd  rib  to  the  umbili- 
cus— early ;  also  an  area 
on  some  part  of  the  face — 
'  masque  tabetique '  or 
Hutchinson's   Mask. 

Morvan's  Disease 

Myelitis 

Neuritis,  Multiple 

Pseudo-tabes 

Syphilis 

Syringomyelia 

Transverse     Softening      of 

Cord 

Lesions  of  medulla  and  optic 
thalamus. 


190.  Analgesia,   Deep 

This  is  tested  by  pinching 
muscles  or  tendons  or 
by  pressure  upon  sub- 
cutaneous bone  such  as 
the  shin. 

Locomotor  Ataxy 

Pseudo-tabes 

Syringomyelia 

191.  Hyperalgesia 

The  pain  of  a  pin- prick  is 
out  of  all  proportion  to 
the  injury.  Inflamma- 
tory tenderness  may  be 
distinguished  by  the 
presence    of    local    heat. 

Multiple  Neuritis 

Optic  Thalamus,  Lesion  of 
***  It  is  present  in  the  repair 
stage    of    divided    nerve, 
before     the      return     of 
epicritic    sensibility. 

192.  Muscular  Hyperalgesia 

Intense  pain  is  experienced 
when  a  muscle  is  grasped. 

Neuritis 

193.  Remak's  Sign 

A  pin- prick  gives  a  double 
sensation,  the  second 
being  the  more  painful. 

Locomotor  Ataxy 

194.  Haphalgesia 

Intense  pain  is  produced 
by  even  a  light  touch. 

Hysteria 

188-194 


ALGESIC 


75 


195.  Illusional   Pain  (Akinesia 
Algera) 

Hysteria 
Neurasthenia 

196.  Anaesthesia  Dolorosa 

Pain  in  a  part  that  is  both 
anaesthetic  and  analgesic. 
Compression  of  Cord 


197.  Simultaneous  Polyalgesia 

A  single  pin -prick  feels  as 
if  several  had  been  made. 

Spinal  Cord  Affections 


195-197 


76 


SENSATION 


198.  SENSATION 

199.  Sensation  Tests. — To  test  with  precision  the  degree 
of  sensation  present,  Weber's  aesthesiometer  is  employed. 
The  standard  is  the  distance  at  which  two  points  are  felt  separ- 
ately and  a  rough  substitute  is  a  pair  of  compasses.  Normally, 
the  distance  for  various  regions  is  as  follows  :  Tip  of  Tongue, 
1  mm.  ;  Underlip,  4  mm.  ;  Back  of  Hand,  25  mm.  ;  Back  of 
Neck,  50  mm.  ;  Mid-dorsal  Region,  Mid-forearm  and  Mid- 
thigh,  all  62  mm.  The  palms  and  parts  covered  with  hair 
are  not  available.  In  ordinary  practice,  however,  the  skin  is 
lightly  brushed  with  a  little  jeweller's  wool.  One  side  should 
be  compared  with  the  other  and  results  checked  by  asking  the 
patient  to  put  his  finger  on  the  spot  just  touched. 

200.  Janet's  Test  is  useful  to  distinguish  organic  from 
functional  anaesthesia.  The  patient  is  told  to  say  '  yes  '  or 
'  no  '  according  to  whether  he  feels  or  not.  Then,  the  eyes 
being  closed,  the  skin  is  lightly  touched  at  various  points. 
If  functional,  the  answer  will  be  '  no  '  when  an  anaesthetic 
area  is  touched  ;  if  organic,  no  answer  will  be  given,  for  he 
will  not  be  conscious  that  he  has  been  touched  at  all. 

As  the  result  of  pressure  and  of  vascular  disease,  the  sense 
of  pain  is  lost  first,  then  the  temperature  sense,  and  lastly  the 
sense  of  touch.  In  lesions  affecting  the  centre  of  the  cord,  such 
as  syringomyelia,  the  order  is  pain,  heat,  and  cold,  concurrently 
with  diminution  of  tactile  sensibility.     (See  85.) 


201.  Hyperaesthesia 

This  can  usually  be  dis- 
tinguished .  from  tender- 
ness by  the  skin  or  muscle 
being  unduly  sensitive 
after  it  has  been  raised 
from  the  subjacent  tissues, 
and  it  may  be  elicited  by 
the  lightest  brush  with 
the  finger. 

Acute  Bronchitis 

sternal 

Alcoholism 
Appendicitis 
right  iliac  region 


Arsenic -poisoning 
Brown-Sequard's  Paralysis 
paralysed  side 

Caries,  Spinal 
above  ana-sthctic  area 

*Clavus  Hystericus 

Compression  of  Cord,  i. 

Cord,  Degeneration  of 

Encephalitis 

Herpes  Zoster 

Hyperaemia  of  Brain 
*Hysteria 

esp.  mammary  and  ovarian 
198-201 


SENSATION 


77 


Hyperesthesia — continued 
Injuries  of  Nerves 

especially  gunshot  wounds 
Locomotor  Ataxy- 
Mania,  Acute 
Meningitis,  Cerebro-spinal 
„  Int.  Spinal 

,,  Simple 

„  Tuberculous 

Spinal 
Myelitis,  Acute 
*Neuralgia 

esp.  trigeminal — sometimes 
unilateral 

*Neurasthenia 
*Neuritis,  I. 
*Ovarian  Disease 

Pachymeningitis,     External 
Spinal,  i. 

Peritonitis 

Pernicious  Anaemia 

Pregnancy 

Rickets 

Spinal  Concussion 

Spinal     Meningeal  Haemor- 
rhage 

Tumours  of  Brain 

202.  Anaesthesia 

The  upper  limit  of  anaes- 
thesia in  the  trunk  serves 
as  a  guide  to  the  localisa- 
tion of  the  lesion  in  the 
spinal  segment.  The  an- 
aesthetic area,  especially 
in  hysteria,  sometimes 
coincides  with  the  tract 
covered  by  a  given  gar- 
ment; thus,  glove-,  shoe-, 
and  stocking-anaesthesia 
are  recognised. 

Aneurysm    of    Desc.    Aorta 
3rd  and  4th  interspaces 


Anterior     Crural     Paralysis 

thigh  and  inner  sido  of  leg 
and  foot 

Apoplexy 

paralysed  side,  unless  pons 
or  medulla  be  the  seat 

Apoplexy,  Spinal 

lower  extremities 
Brown-Sequard's  Paralysis 
Caisson  Disease 
Catalepsy  (if  severe) 
Cerebral  Hyperaemia 
„       Tumours 

esp.  of  pons 

.  Cerebro-spinal   Meningitis, 

in. 
Chorea 

Compression  of  Cord,  n. 
when  gradual 

Concussion  of  Spine 
Dementia  Praecox,  i. 
Diphtheritic  Paralysis 
Disseminated  Sclerosis 
Embolism 

Fracture  of  Sup.  Maxilla 
Friedreich's  Disease 
legs 

General  Paralysis  of  Insane 
Haematomyelia 
Haemorrhage     into     Spinal 

Arachnoid 
Herpes  Zoster 

between  vesicles 

Hypertrophy  of  Brain 
*Hysteria 

esp.  plantar  and  palatine 
Klumpke's  Paralysis 

inner  side  of  arm 
Lead-poisoning 
Lepra  anaesthetica 

201-202 


78 


SENSATION 


A:n  jESthesia — continued 

Locomotor  Ataxy 

chest,  glans  penis,  and 
soles.  Also  tendo  Achillis 
(Abadie's  Sign)  and  the 
popliteal  space  (Bech- 
terew's  Sign) 

Meningitis,  Simple 

„  Spinal,  in. 

Morvan's  Disease 
Myelitis,  Acute,  n. 

„        Chronic 
Neuritis 

most  marked  at  periphery 

Neuroma 

Pressure  on  Nerve -trunk 

Raynaud's  Disease 

Sciatica 

Softening,  Chronic  (x) 

Spinal         Pachymeningitis, 

Ext,  ii. 
Syringomyelia 

arms  and  chest 

Tetany 

Thrombosis 

Transverse    Softening    of 

Cord 

lower  extremities 

Tumours  of  Cord 
Typhic  State  (62) 
Unilateral  Lesion  of  Cord 

if  dorsal  region,  one  leg 
(See  Numbness,  215) 

03.  Dissociated  Anaesthesia 

Retention  of  tactile  sensi- 
bility combined  with  loss 
of  heat  sense  and  of  pain 
sense. 

Brown-Sequard's  Paralysis 
Hsematornyelia 


Hysteria 
Multiple  Neuritis 
Syringomyelia 
Thrombosis 

of    posterior  inferior   cere- 
bellar artery 


204.  Hemianaesthesia    (Sensa- 
tion absent  on  one  side) 

Due,  when  organic,  to  a 
lesion  involving  the  pos- 
terior third  of  the  in- 
ternal capsule ;  but  it 
is  often  functional. 

Apoplexy  (x) 

Brown-Sequard's  Paralysis 
Cerebellar  Disease 
s.  of  opposite  side 

Disseminated  Sclerosis 
*Hemichorea 

Hereditary-cerebellar  Ataxy 
♦Hysteria 
left  side  \ 

♦Occupation  Neurosis  (27) 
♦Paralysis  of  5th  Nerve 

Thrombosis   or  Rupture   of 
Posterior  Cerebral  Artery 

Tumour  of  Brain 

Unilateral  Atrophy  of  Brain 

205.  Allocheiria 

(Bamberger's  Sign) 

A  touch  on  one  side  is  felt 
on  the  opposite  side  (rare). 
It  is  due  to  a  unilateral 
destructive  lesion  of  the 
cord. 

Allied  to  this  is  the  pain, 
or  even  tenderness,  some- 
times felt  on  the  side 
opposite  to  the  lesion ; 
e.g.  in  the  left  hypo- 
chondrium  in  hepatic  colic . 

202-205 


SENSATION 


79 


Allocheiria — continued 
Callus,  Pressure  of 
Disseminated  Sclerosis 
Endarteritis,  Syphilitic 
♦Hysteria 
Locomotor  Ataxy 
Myelitis,  Partial 
Subluxation,  Spinal 
Thrombosis,  Spinal 
Trauma 


206.  Retarded  Sensation 

The  pain  or  sensation  is 
felt  many  seconds  after 
the  stimulus  (rare). 


Locomotor  Ataxy 
Multiple  Neuritis 


207.  Astereognosis 

The  patient,  blindfolded,  is 
unable  to  recognise  solid 
bodies  by  touch 

Cerebral  Haemorrhage 
„       Tumour 

or  other  coarse  lesion 


208.  Muscular  Sense 

Kinesthesia  can  be  tested 
by  making  the  patient 
distinguish  between  two 
dark  bottles  of  the  same 
shape  and  size  —  one 
empty,  the  other  full. 
In  the  case  of  the  legs, 
the  bottles  can  be  ban- 
daged one  to  each  foot. 

A  normal  person  recognises 
an  increase  of  one-third 
the  weight  (Weber's  Law). 


The  lesion  is  in  the  deeper 
layers  of  the  cortex. 

The  sense  is  impaired  or  lost 
in — 

Brown  Sequard's  Paralysis 
Cerebral  Haemorrhage 

,,       Thrombosis 

„       Tumour 

Hysteria 

Locomotor  Ataxy 

Neuritis 

Syringomyelia 

Transverse  Myelitis 

For  Joint  Sense,  which  is 
sometimes  included  under 
muscular  anaesthesia,  see 
209. 


209.  Posture  Sense 
(including  Joint  Sense) 

Passive  movements  of  a 
limb  having  been  made 
with  the  patient's  eyes 
shut,  he  is  asked  to  imi- 
tate the  movements  and 
posture  with  the  sound 
limb.  The  sense  is  un- 
impaired in  cerebellar 
lesions,  but  may  be 
aSected  in — 

Cortical  Lesions 
Hysteria 

Locomotor  Ataxy 
Neurasthenia  (x) 


210.  Atopognosis 

The  blindfolded  patient, 
when  pointing  to  the 
spot  just  touched,  makes 
an  error  of  several  inches 
— and  always  too  high. 


Cortical  Lesion 


205-210 


80 


SENSATION 


211.  Thermesthesia     (Tempe-      214.   Vibration  Sense    (Pallses- 


rature  Sense) 

This  may  be  determined 
with  the  aid  of  two  spoons, 
one  hot,  the  other  cold, 
applying  them  to  various 
areas  and  making  the  pa- 
tient distinguish  between 
them.  The  tip  of  the 
tongue  is  not  nearly  so 
sensitive  to  heat  as  is 
the  check  or  forearm. 
(See  85) 

212.  Lost  or   Diminished 

Brown  Sequard's  Paralysis 
opposite  side 

Bulbar  Paralysis 
*General  Paralysis 

Hcematomyelia 

Lepra  Ansesthetica 
*Locomotor  Ataxy 

Syringomyelia 

Transverse      Softening      of 
Cord 

213.  Increased 
Cerebro-spinal  Meningitis 
Degeneration     of     Cerebral 

Ganglia 
Neuritis 

Heat  applied  to  an  inflamed 
part  increases  the  pain 
when  pus  is  present,  but 
diminishes  it  when  absent. 


thesia) 

A  largo  Cl  tuning  fork 
should  be  placed  vibrating 
on  the  nails,  the  heads  of 
the  metacarpal  or  meta- 
tarsal bones,  or  on  the 
shin. 

When  there  is  loss  of  other 
forms  of  sensation,  the 
vibration  sense  is  also 
usually  lost,  but  its  loss 
may  precede  cutaneous 
anaesthesia. 

Lost 

Brown-Sequard's  Paralysis 

opposite  side 

Compression  Myelitis 
Diabetes 

Disseminated  Sclerosis 
Growth,  Spinal 
Hemiansesthesia,  Hysterical 

opposite  side 

Locomotor  Ataxy 
Peripheral  Neuritis 
Spinal  Syphilis 
Transverse  Division  of  Cord 

The  cord  lesion  must  be  in 
a  part  from  which  the 
bone  tested  derives  its 
nerve  supply. 


PARESTHESIA,  ETC. 


215.  Numbness 

Aconite  -poisoning 
Acroparaesthesi  a 

fingers,      toes,      lips,      and 


tongue 


Aneurysm 
Appendicitis 

right  leg — early 


Apoplexy  (prsem.) 

,,  Spinal 

Arteritis 
Aura  epileptica 
Beri-beri 
Bromism 
Cervical  Rib 
hand 

Circulation,  Defective 

211-215 


SENSATION 


81 


Numbness — continued 
Disseminated  Sclerosis 

often  unilateral- 
Emboli 

Erb's  Spinal  Paralysis 
Hyperemia,  Spinal 
Hysteria 

*Hysterical  (Edema 
Leprosy 

*Locomotor  Ataxy 
Meralgia  Paresthetica 

outer  side  of  thigh 
Myelitis,  Acute 
Myxcedema 
Neuralgia  (prsem.) 
Neurasthenia 
Neuritis 
Neuroma  (x) 
^Pressure     upon     a     Nerve  - 

trunk 
Recklinghausen's  Disease 
Sciatica 

Sigmoid,  Loaded 
Spinal  Tumour 
Softening,  Chronic 
Syringomyelia 
Tetany 
Thrombosis 

(See  Anaesthesia  202) 

216.  Biernacki's  Sign 

The  well-known  '  funny- 
bone  '  sensation  is  absent. 

Dementia 

General  Paralysis 

Idiocy 

Locomotor  Ataxy 

217.  Magnan's  Sign 

A  subjective  feeling  as 
of  sand  or  worms  under 
the  skin. 

Cocaine  Habit 


218.  Itching,   Formication,  or 
Tingling 

These  are,  for  convenience' 
sake,  all  put  under  one 
heading. 

Anaemia  of  Brain 
Aneurysm 
Apoplexy  (praam.) 
Arsenic-poisoning 
Arteritis 
Arthritism 
Aura  epileptica 
Cervical  Rib 
hand 

Cheiropompholyx 

Chilblain 

Chloasma 

Copaibism 

Dermatitis 

„  Herpetiformis 

^Desquamation 
*Diabetes  Mellitus 
pubes 

Disseminated  Sclerosis 
Drug  Rashes 
Dysidrosis 
*Eczema 
Embolism 
Encephalitis 
Erb's  Spinal  Paralysis 
Ergotism 
Erythema 

Fsecal  Accumulation 
Gout 

Haemorrhoids 
Hydroa 

Hyperemia  of  Brain 
Hypertrophy  of  Heart 
Hypochondriasis 
Hysteria 

Irregular  Circulation 
Irritating  Clothing 

215-218 


82 


SENSATION 


Itching,     Formication,     or 
Tingling — continued 
Jaundice 

Lichen 

Leucorrhoea 

Locomotor  Ataxy 

Lymphadenoma 

Meningeal         Haemorrhage, 

Spinal 
♦Menopause 

pruritus  vulvae 
Meralgia  Paraesthetica 

thigh 
Mycosis  Fungoides 
Myelitis 
Nephritis 

Neurasthenia,  Traumatic 
Neuritis,  I. 
*Pediculi,  etc. 
Pemphigus  (x) 
Pityriasis  rubra 
Pressure  on  a  Nerve 
Prickly  Heat 
♦Prurigo 

usually  due  to  lice 

*Pruritus,  Bathing 
„  Senilis 

Psoriasis,  I. 

Pyodermatitis  Vegetans 
♦Scabies 

Sciatica 

Scleroderma 

Seborrhcea 

Spinal  Apoplexy 
„       Hyper  aemia 
„       Meningitis 

Syphilitic  Spinal  Paralysis 

Syringomyelia 

T3tany 

Thrombosis 

Tumours  of  Brain 


Tumours  of  Spinal  Cord 
♦Urticaria 

Uterine  Disease 

Variola 
*Worms 

mucous  orifices 

Also  stings  of  insects,  jelly 
fish  or  plants. 


219.  Palpitation 

The  patient  is  conscious  of 
his  heart  beats. 

Amenorrhcea 
*Anaemia 
Aneurysm,  Thoracic 
Angina  Pectoris 
Arterio- sclerosis 
Ascites 
Chlorosis 

Cirrhosis  of  Kidney 
Dyspepsia,  Flatulent 
Epilepsy 

Exophthalmic  Goitre 
Fatty  Heart 
Fibroid  Heart 
♦Hysteria 
Locomotor  Ataxy 
Malformations  of  Heart 
Mediastinal  Growth 
Menopause 
♦Neurasthenia 
Ovarian  Cyst,  Large 
Paroxysmal  Tachycardia 
Pericarditis 

Pericardium,  Adherent 
Pernicious  Anaemia 
Pregnancy 
Pseudo-Angina 
Spermatorrhoea 
Tumours,  Abdominal 
Tympanites 

218-219 


SENSATION 


83 


Palpitation — continued 
Valvular  Diseases 
Ventricle,  Dilated  Right 

Palpitation  may  also  bo 
caused  by  cocaine,  digita- 
lis, thyroidin  or  morphia, 
as  well  as  by  excessive 
use  of  tea,  coffee,  tobacco, 
alcohol  or  absinthe. 


220.  Heartburn  (Cardialgia) 

Due    to   lactic    or    butyric 
acid. 

Cancer  of  Stomach 
♦Dilatation  of  Stomach 

Gastralgia 

Gastritis 
♦Indigestion 

esp.  of  fatty  food 

♦Pregnancy 
Ulcer  of  Stomach 
,,     of  Duodenum 


221.  '  Precordial  Anxiety  '  or 
Sinking  Feeling 

Aneurysm 
♦Angina  Pectoris 

Aortitis 

Arsenic-poisoning 

Asthenia  in  general 

Atony  of  Stomach 

Beer-Heart 

Cholera 
♦Dilatation  of  Heart 

Displacement  of  Heart 

Fatty  Heart 

Fibroid  Heart 
♦Flatulence 

Lithsemia 

Melancholia 

Myocarditis,  Acute 


♦Neurasthenia 
Pericarditis 
Syphilitic  Heart 
Valvular  Disease 


222.  Girdle  Sensation 

A  feeling  like  that  produced 
by  a  tight  girdle.  It 
marks  the  upper  limit 
of  a  cord  lesion. 

Ataxic  Paraplegia  (x) 
♦Crushing  Lesion  of  Cord 
Disseminated  Sclerosis 
Erb's  Spinal  Paralysis 
Locomotor  Ataxy  (x) 
♦Myelitis,  Transverse 
Paraplegia,  Spastic 
Spinal  Meningitis,  Syph. 
Traumatic  Spondylitis 
Tumours  of  Cord 

A  sprained  diaphragm  from 
vomiting,  etc.,  produces 
a  similar  sensation,  as  also 
does  double  intercostal 
rheumatism. 


223.  Sensation  of  Local  Heat 

Erythromelalgia 

feet 
Exophthalmic  Goitre 
*Influenza 
Irritant-poisoning 

epigastrium  and  throat 
Locomotor  Ataxy 
♦Menopause 
Neurasthenia 

vertex 
Paralysis  Agitans 

epigastrium  and  back 
Rectum,  Cancer    of 

(See  Heartburn,  220) 

2  219-223 


84 


SENSATION 


Cold,  Sensation  of 

(Sec  Chills,  239) 

224.  Sweating,  Sensation  of 
The  skin  being  dry. 

Haematonryelia 
Syringomyelia 

225.  Throbbing,  Sensation  of 

This  may  be  due  to  actual 
increase  of  pulsation,  to 
extra  -  sensitiveness  to 
normal  pulsation  or  to 
clonic  muscular  spasm 
(myokymia). 

*Abscess 

*Ana3mia 

*Aneurysm 

*Aortic  Regurgitation 
'  Beat  Knee  ' 
Exophthalmic  Goitre 
Headache,  Congestive 
Heart,  Hypertrophy  of 
Hysteria 

Inflammation,  Local 
Migraine 
Neurasthenia 

*Palpitating  Aorta 
Palpitation 

(See  Abnormal  Pulsation, 
284) 

226.  Sensation  of  Fulness 

Atony  of  Stomach 
*Dilatation  of  Stomach 

Emphysema 

Fatty  Degeneration  of  Heart 

Gastric  Irritation 
*Gastritis,  Chronc 

Goitre,  Exophthalmic 

Hepatic  Enlargements 

Hypertrophy  of  Heart 


*Hystcria 

in  throat — Globus  Hystericus 

Malaria 
*Menopause 

in  throat — Globus  Hystericus 

Peritonitis,  Chronic 

Remittent  Fever 
*Tympanites 

227.  Sensation  of  Weight 

Angina  Pectoris 

Asthma 

Apoplexy  (prsem.) 

Aura  epileptica 

Cirrhosis   of   Liver,    Hyper- 
trophic 

Dilatation  of  Heart 

Displacement  of  Heart 

Dyspepsia 

Endocarditis,  Acute 

Exophthalmic  Goitre 
*Fsecal  Accumulation 

Flatulence 

Gastric  Irritation 

Gastritis,  Chronic 

Hajmatemesis  (prsern.) 
epigastrium 

Haemoptysis  (proem.) 
sternum 

Lithaemia 
epigastrium 

Neurasthenia 
limbs 

Neuritis,  Multiple,  I. 
limbs 

Paralysis,  Flaccid 

Stomach,  Atony  of 

,,        Dilatation  of 

Syphilitic  Liver 

Trichinosis 

224-227 


SENSATION 


85 


228.  Sensation    of    Bearing 
Down 

*Abortion  (threatened) 

Cervicitis 

Cervix,  Hypertrophied 

Distension  of  Bladder 

Dysnienorrhoea 

Endometritis,  Hypertrophic 
*Enteroptosis 
*Faecal  Accumulation 

Haemorrhoids 
*Labour 

Metritis 

Ovarian  Cyst 
*Prolapsus  Uteri 

Periproctitis 

Prostatitis 

Rectum,  Cancer  of 
„        Ulcer  of 

Retained  Menses  or  Decidua 

Retroversion 

Subinvolution 

Tumours,  Pelvic 
esp.  if  impacted 

Uterine  Fibroid  or  Polypus 
Uterus,  Congestion  of 

,,       Inversion  of 
(See  Tenesmus,  1081) 

229.  Sensation  of  Oppression 

*Aneurysm,  Thoracic 
*Angina  Pectoris 

Aortitis 
*Asthma,  Spasmodic 

'  Beer  Heart ' 
*Dyspepsia 

Emphysema 

Exophthalmic  Goitre 

Hysteria 
*Mediastinal  Tumour 
*Pericardial   Effusion 
(See  Weight,  227) 


230.  Faintness  (with  or  with- 
out giddiness) 
Less      important      if      the 
patient  has  always  been 
subject  to  faints. 

*  Addison's  Disease 
*An3emia 

Aneurysm 
*Angina  Pectoris 

Aortic  Cusp,  Rupture  of 
,,       Disease 

Ascites 

Blows 

esp.  over  solar  plexus 

Bradycardia 
*Dilatation  of  Heart 
*Diphtheria,  m. 

Dissecting  Aneurysm 

Emotion 

Exhaustion 

Fatty  Degeneration  of  Heart 
^Flatulence 

Haemorrhage 
*Heated  Air 

Intercostal  Neuralgia 

Leukaemia 

Meniere's  Disease 

Pain,  Acute 

Perforation  of  Bowel 

Pleural  Effusion 
(esp.  left) 

Pneumothorax 

Poisoning  by  Depressants 
*Pregnancy 

*  Quickening 
♦Shock 

Stokes-Adams'  Syndrome 
*Strangulated  Hernia 
Syphilitic  Heart 
Tapeworm 

Thrombosis  of  Pulm.  Artery 
„  of  Superior  Mes- 

enteric Artery 

228-230 


86 


VERTIGO 


231.    VERTIGO  OR  GIDDINESS 

Vertigo  may  bo  divided,  though  with  some  over-lapping, 
into  :  Nervous,  Gastric,  Toxic,  Ocular,  Aural,  and  Circulatory.  If 
the  vertigo  is  improved  by  closing  the  eyes,  ocular  trouble  or 
neurasthenia  is  probable  ;  if  made  worse,  locomotor  ataxy  and  the 
diseases  mentioned  under  '  Romberg's  Symptom  '  must  be  thought 
of  ;  while  if  unaffected,  it  may  be  gastric,  toxic  or  circulatory.  In 
the  case  of  this  last,  pallor  or  perhaps  flushing  will  accompany  it. 
In  doubtful  cases,  vertigo  may  be  brought  out  by  making  the 
patient  turn  suddenly  at  the  end  of  a  short  walk. 


♦Alcoholism 

Aneurysm 

Antral  Abscess 

Aortic  Regurgitation 

Aortitis 

Apoplexy  (prsem.) 
♦Arterio-sclerosis 

Aura  epileptica 

Bulbar  Paralysis 

(prscm.) 

Catalepsy 

Cervico  -  occipital         Neur- 
algia 

Cinchonism 

Cirrhosis  of  Kidney 
*  Constipation 

Corrosive-poisoning 
♦Dilatation  of  Stomach 

'  vertigo  a  stomacho  lseso  ' 

Disseminated' S  clerosis 
Encephalitis 
Epilepsy 
♦Eyestrain 

esp.  of  oblique  muscles 

Facial  Paralysis 

onset 

Gastritis,  Chronic 
Gerlier's  Disease 


Hsematoma      of     Dura 

Mater 
Hemianopsia 
Hereditary      Cerebellar 

Ataxy 
Hydrocephalus,  Chr. 
Hypersemia  of  Brain 
Hypertrophy  of  Heart 
Jaundice 

Labyrinthine  Growths 
Labyrinthitis 
Laryngeal  Vertigo 
Lithsemia 
Mastoid  Abscess 
♦Meniere's  Disease 
Middle  Ear  Catarrh 
Migraine 

Miner's  Nystagmus 
♦Neurasthenia 
Pellagra 
Petit  Mai 
Plague 
Polycythemia,  Splenome- 

galic 
Ptomainism 
Stapes,  Ankylosis  of 
Stokes- Adams'  Disease 
Tumour  of  Brain 

lesions  of  pons,  c.  quad- 
rigemina,  cerebellum, 
or  middle  cerebellar 
peduncle 

231 


VERTIGO 


87 


Vertigo  or  Giddiness- 
tinued. 
Typhus 

invasion  stage 
Wax  in  Meatus 


-con- 


Weil's  Disease 
Also  tight  collars,  abuse  of 
tea      or     tobacco,      and 
numbed  feet. 

(See    Gait,    1295;     Mai-Co- 
ordination, 1303) 


231 


88 


WEAKNESS 


232.  WEAKNESS 

Almost  all  diseases.     The  three  following  sections  differ  only  in 
degree. 


233.  Lassitude  and  Debility 

♦Addison's  Disease 
♦Anaemia 

Atony  of  Stomach 

Carcinoma 
*Chloroma 
*Chlorosis 

Convalescence    from    Acute 
Disease 
♦Diabetes 
*Dilatation  of  Heart 

Dysentery 
*Exophthalmic  Goitre 

Faecal  Accumulation 

Incubation  Stage  of  Exan- 
themata 
♦Influenza,  III. 

Jaundice 
♦Leukaemia 

Lipomatosis  neurotica 

Lithaemia 

Myxcedema 

Nephritis 
♦Neurasthenia 

Pancreatic  Disease 

Phthisis 

Pyelitis,  Chronic 

Pyrexia 

Scurvy 

Trypanosomiasis 


234.  Prostration 

Acute  Yellow  Atrophy 
Buhl's  Disease 
Cancrum  Oris 
♦Cholera 


Concussion     of     Brain     or 
Spine 

Diarrhoea  (severe) 

Dysentery,  in. 
♦Embolism     of     Pulmonary 

Artery 
♦Endocarditis 

Eat  Embolism 

Gangrene  of  Lung 

Glanders 

Hepatic  Colic 
♦Haemorrhage 

Hyperpyrexia 

Inversion  of  Uterus 

Plague 

Pellagra 

Ptomainism 

Relapsing  Fever 

Tobacco -poisoning 

Trichinosis 

Tuberculosis,  Acute 
♦Typhic  State  (62) 


235.  Collapse 

Alcoholism,  Acute 

Aniline-poisoning 

Embolism     of     Pulmonary 
Artery 
♦Haemorrhage,  Profuse 
♦Hernia,  Gangrenous 

Hydrophobia,  hi. 

Perforation  of  Diaphragm 
♦Perforation  of  Intestine 
♦Perforation  of  Stomach 

Pneumo  -pericardium 

232-235 


WEAKNESS 


89 


Collapse — continued 

Poisoning   by    Aconite   and 
Heart   Depressants   gene- 
rally 
*Rupture  of  Bladder 

„         of  Ectopic  Amnion 


Rupture  of  Heart 
,,        of  Liver 
„         of  Ovarian  Cyst 
„        of  Spleen 
*Hupture  of  Uterus 


v 


235 


90 


RIGORS    AND    CHILLS 


236.  RIGORS  AND  CHILLS 

The  beginning  of  almost  all  pyrcxial  diseases  of  sudden  onset 
is  marked  by  a  rigor  or  chill,  as  also  is  the  supervention  of  suppuration 
or  sepsis  in  the  course  of  an  acute  disease. 


237.  Rigors  or  Shivering  Fits 

Usually  initial. 

Abscess,  Cerebral 
Hepatic 
Pelvic 
Prostatic 
Rectal 
Renal  **• 
Subphrenic/- 
Appendicitis  /■> 
*Calculus,  Passage  of  *-■ 
Catheterisation 
Cholecystitis,  Suppurating  k 
Colic  (x)       ^ 
*Diphtheria 
Empyema 

Endocarditis,  Septic 
Enteric  Fever 

perforation 
Erysipelas 

Erythema  Scarlatiniforme 
Hemoglobinuria,  Parox. 

onset 
Hydatids,  Suppurating 
Influenza 
Malaria 
Meningitis,  Simple 

„  Cerebro-spinal 

,,  Internal  Spinal 

Milroy's  Disease 

acute  crisis 
Myelitis,  Acute 
Nephritis,  Acute    r~ 
Pelvic  Peritonitis 
Periarteritis  nodosa 


Peritonitis,  Acute 
Phthisis,  Acute 
*Pneumonia,  Acute 
Poliomyelitis,  Acute 
Portal  Phlebitis 
suppuration 

Pyaemia 
Pyelitis,  Acute 
Relapsing  Fever 
Renal  Embolism 
Rheumatism,  Acute 
Scarlatina  (x) 
*Septicsemia 
Suppurative  Spinal  Pachy- 
meningitis 
„  Synovitis 

Thrombosis 
Tuberculosis,  Acute 
Typhus 
*Variola 
Weil's  Disease 

onset 
Woillez's  Disease 

onset 
Yellow  Fever 

In  an  infant,  convulsions 
often  take  the  place  of  a 
rigor. 

238.  Recurring   Rigors 

Actinomycosis 
Cholecystitis 
Cystitis  (x) 

Endocarditis,  Ulcerative 
*Gallstones 

236-238 


RIGORS    AND    CHILLS 


91 


Rectjrrikg      Rigors  —  con- 
tinued 
Glanders 
Influenza  (x) 
Leukaemia,  Acute 
Lymphosarcoma,  Acute 
Malaria 

Osteomyelitis,  Acute 
Pancreatitis,  Acute 
Perinephritis 
Phthisis,  Acute 
Pleurisy  (x) 
Pyelitis,  Calculous 
Pyelonephritis 
Pyaemia 

„  Portal 

*Renal  Calculus 
Septicaemia 

Syphilis,  Secondary  (x) 
Tuberculosis,  Acute 

239.  Chills  and  Subjective  Cold 

Pelt  chiefly  in  the  back. 
Chills  are  often  a  mild 
form  of  rigor. 

Coryza  (x) 
Dysentery 


Erysipelas 

Glanders,  I. 

Haematomyelia 

Herpes  Laryngis 

Hysteria 
*Influenza 

Locomotor  Ataxy 

Malaria 

Migraine,  i. 

Mumps 

Myxcedema 
*Neurasthenia 

Neuritis,  i. 

Paralysis  agitans 

Periarteritis  nodosa 

Phthisis,  Acute 

Pleurisy,  Acute 

Pyonephrosis 

Remittent  Fever 

Rheumatism,  Acute 

Salpingitis 

Sclerosis,  Lateral 

Spasmodic  Spinal  Paralysis 

Spinal  Meningitis 

Syringomyelia 
*Tonsillitis,  Follicular 


238-239 


92 


PULSE 


PART  II 

INSPECTION  AND  OBSERVATION 

Contractions  :    u,  usually ;    x,  exceptionally  ;    *,  the  most  likely 
diseases  ;    i,  First  stage  ;   n,  Second  stage  ;   in,  Third  or  Final  stage. 


240.  THE  PULSE 


Normal  Rate 


1st  year 130-115 

2nd  year 115-100 

3rd  year 100-90 

7th  year 90-85 


14th  year 85-70 

Adult  age 80-70 

Old  age       70 -CO 

Decrepitude        .  .      .  .  75—65 


The  pulse  is  best  felt  with  the  patient's  forearm  pronated  and 
it  should  not  be  counted  until  the  patient  has  become  accustomed 
to  the  presence  of  the  physician.  If  the  artery  appears  small, 
the  pulse  of  the  other  hand  should  be  felt,  as  there  may  be 
some  abnormal  distribution.  The  force  or  pressure  is  roughly 
determined  by  placing  three  fingers  on  the  radial  artery  and 
estimating  what  pressure  of  the  proximal  finger  is  necessary 
to  prevent  the  pulse  being  felt  by  the  other  two.  It  is  high 
when  the  artery  is  full  between  the  beats  and  can  be  rolled  under 
the  finger  like  a  tendon.  For  exact  results,  the  sphygmometer 
is  necessary  (see  Tension).  The  artery  between  the  pulsations, 
owing  to  the  pressure  of  the  finger,  is  transversely  oval,  so  that 
each  pulsation,  by  altering  the  shape  to  circular,  produces  under 
the  finger  a  feeling  of  distension.  In  the  erect  position  the 
pulse  averages  nine  beats  per  minute  more  than  in  the  recumbent, 
and  every  increase  of  1°  F.  in  the  temperature  sends  up  the 
pulse  about  eight  beats. 


241.  Quick  (Pulsus  frequens, 
or  if  very  rapid, '  Tachy- 
cardia ') 

The  pulse  is  quickened 
under  the  influence  of 
exertion  or  excitement 
and  in  all  febrile  diseases, 
except  in  yellow  fever  and 
where    there  is    pressure 


on  the  brain.  When  the 
pulse  is  quickened  it  is 
the  diastole,  not  the 
systole,  that  is  shortened. 
(See  Pyrexia,  295) 

Ac.  Ascending  Paralysis 

Addison's  Disease 

Anaemia 

Aneurysm  of  Aorta 

240-241 


PULSE 


93 


Qu  rcK — continued 
Angina  Pectoris 
Appendicitis 
Belladonna -poisoning 

Chlorosis 

Chorea 

Collapse 

,,       of  Lungs 
Coma  Vigil 

Concussion  of  Brain  or  Cord 
Displaced  Heart 
Epilepsy,  n. 
Excitement 
Exertion 

Exophthalmic  Goitre 
except  during  sleep 

Foreign  Body  in  Heart 
Gout,  Undeveloped 
Haemorrhage 
Hernia,  Strangulated 
Irritation  of  Sympathetic 
not  above  120 

Leukaemia 
Lesion  of  Medulla 
Locomotor  Ataxy 
Mediastinal  Growth 
Mitral  Stenosis 
Neurasthenia 
Periarteritis  nodosi 
Pericarditis,  Acute 
Pernicious  Anaemia 
Phthisis,  Incipient 
Pneumogastric  Paralysis 

but  not  over  160 
Pneumogastric  Neuritis 

influenzal,  diphtheritic,  etc. 
Pneumonia,  Acute 

90    to     120,    less    than    is 
usual  with  such  a  tem- 
perature.    (See  267) 
Pneumothorax 


Pregnancy 

Rheumatoid  Arthritis 
Shock 

Sunstroke,  Syncopal 
Tachycardia,  Paroxysmal 
Tobacco  Heart 
Typhic  State  (62) 
Typhus 

Pulsus  celer  is  not 
necessarily  frequent.  (See 
250.) 


242.  Slow     {Palsies     rants) — 
Bradycardia 

Bradycardia  is  '  muscular ' 
when  the  Bundle  of  His 
is  affected  and  '  nervous  ' 
when  due  to  direct  or 
reflex  irritation  of  the 
vagus.  Some  of  the  pul- 
sations may  not  reach  the 
radial  artery  and  the  rate 
must  be  checked  by 
auscultation. 

Aortic  Stenosis,  i. 

Arterio -sclerosis 

Asthma,  Spasmodic 

Atonic  Dyspepsia 

Chlorosis 

Cerebral  Abscess 
,,        Aneurysm 
,,         Haemorrhage 

Cirrhosis  of  Lung 

Colic  (x) 
*Coma 

Compression  of  Cord 
upper  part 

Convalescence    from    Pneu- 
monia and  Fevers 
Coronary  Sclerosis 
Diabetes 

241-242 


94 


PULSE 


Slow — continued 
Diphtheria 

sequela 
Enteric  Fever 

relatively 
Epilepsy- 
Ergotism 
*Fatty       Degeneration       of 

Heart 
Fibroid  Heart 
Gallstones 
Gastric  Cancer 

„       Ulcer 
General  Paralysis 
Hydrocephalus 
Influenza  (x) 
*Irritation  of  Pneumogastric 
by    tumours,      etc.       This 
cause    can    be    counter- 
acted by  atropine 

Jaundice  (392) 

Lead  Colic 

Lesion  of  Medulla 

Liver,  Ruptured 

Melancholia 
*Meningitis,  n. 
♦Meningitis,  Tuberculous,  II. 

Mumps  (x) 

Myxcedema 

Paralysis  of  Sympathetic 

Pregnancy 

Relapsing  Fever 

Senility 
*Stokes-Adams'  Disease 

from  14 ;  pulse  absent 
during  the  epileptiform 
attack 

Syphilitic  Heart  Affection 
Tumours  of  Brain 
Tumour  of  Heart 
invading  Bundle  of  His 


Yellow  Fever 

***  Exclude  Pulsus  alternans 
and  the  action  of  con- 
vallaria,  digitalis,  lead, 
opium,  salicylates,  stro- 
phanthus  and  conium. 
A  slow  pulse  is  normal  in 
some  individuals.  (See  8.) 


243.  Erben's  Phenomenon 

The  pulse  slows  down  when 
the  patient  leans  forward. 
Neurasthenia 

244.  Pulse       Tardy      {Pulsus 
tardus) 

Slow    rise    and    descent   of 
the   pulse  wave — tension 
high. 
Aneurysm 
Angina  Pectoris 
Aortic  Stenosis 
Arterio-sclerosis 
Contracted  Kidney 
Senility 

245.  Hard  (Pulsus  durus) 
Aortic  Stenosis 
Apoplexy 

*Atheroma 

or,  if  combined  with 
hypertrophy  of  heart, 
'  bounding  ' 

Athleticism 
♦Cirrhosis  of  Kidney 
Diphtheritic  Laryngitis 
Enteritis 
Gout 

Hypertrophy  of  Heart 
Lead  Colic 
Pericarditis,  Acute 
Peritonitis,  Acute 
Pleurisy,  Acute 

242-245 


PULSE 


95 


246.  Soft  and  Compressible  or 
Weak  (Pulsus  mollis) 

*Ansemia 

Aneurysm  of  Heart 

Aortitis 

Asphyxia 

Asthma,  Spasmodic 

Atony  of  Stomach 

Broncho-pneumonia 

Cancer  of  Stomach 

Cholera 

Colic 

Collapse 

Coma  Vigil 

Concussion  of  Brain 

Delirium  Tremens 
*Dilatation  of  Heart 

Diphtheria 

Dysentery 

Gallstones 
severe  attack 

Glanders 

Gout,  Undeveloped 

Haemorrhage 

Hyperpyrexia 

Mitral  Regurgitation 

Pericarditis^  n. 

Perinephritis 

Poisoning  by  Depressants 

Pulmonary  Apoplexy 

Pyaemia 

Pyrexia  (295) 

Rheumatism,  Acute 
*Shock 

Strangulated  Hernia 

Sunstroke 
*Syncope 

Trance 

Typhic  State  (62) 

Typhus 


247.  Full    or    Large    (Pulsus 
magnus) 

Aortic  Regurgitation 
aortitic  form 

Concussion  of  Brain,  III. 
Erysipelas,  I. 
Hypertrophy  of  Heart 

„  with      Dilata- 

tion 
Pericarditis 
Rheumatism,  Acute 
Spinal  Meningitis 

248.  Small  (Pulsus  parvus) 
Ague 

cold  stage 

Angina  Pectoris 

Aortic  Stenosis 

Asthma  (paroxysm) 

Atrophy  of  Heart 

Broncho-pneumonia 

Cholera 

Collapse 

„        of  Lungs 
Dilatation  of  Heart 
Dysentery 
Emphysema 
Endocarditis 
Enteric  Fever 

third  week 
Ergotism 
Fibroid  Heart 
Gallstones 
Gangrene  of  Lungs 
Gout,  Undeveloped 
Hyperpyrexia  (298) 
Intestinal  Obstruction 
Mitral  Stenosis 
Myocarditis,  Acute 
Noma 
Pericardium,  Adherent 

246-248 


96 


PULSE 


Small — continued 
Peritonitis,  Acute 
Pleurisy,  I. 
Pneumonia,  Acute 
late 

Pneumothorax 
Scarlatina 

Strangulated  Hernia 
Typhic  State 
Typhus 
***  Also  abnormal  distribution. 


249.  Sustained  (Pulsus  plenus) 

Pulse  full  between  the  beats. 

Aortic  Stenosis 

if  associated  with  left  hyper- 
trophy 

Contracted  Kidney 
Hypertrophy  of  Heart 
Mitral  Stenosis 


250.  Jerky  (Pulsus  celer) 

Tension  low. 

*  Aortic  Regurgitation 

'  water-hammer  '  or  '  Corri- 
gan's  Pulse  ' — more  evi- 
dent when  the  arm  is 
raised 

Atheroma 

Collapse 

Debility 

Enteritis 

Fatty       Degeneration       of 

Heart 
Fibroid  Heart 
*Ha3morrhage 
Pericarditis  (x) 
Pernicious  Anaemia 
Wasting  Diseases  (311) 


251.  Irritable 

Accelerated  from  slight 
causes. 

Dysentery 

Enteric  Fever,  1st  week 

Hysteria 

Masturbation 

*Neurasthenia 

Spermatorrhoea 

Also  from  nervousness  or 
abuse  of  tea  or  tobacco. 

252.  Thrilling    or    Tremulous 
Anaemia 

Aneurysm 

Aortic  Regurgitation 
with  strong  ventricle 
Neurasthenia 
Septicsemia 

253.  Pulsus  Alternans 

Pulse  beats  unequal  in 
strength. 

Weakness  of  Myocardium 

254.  Pulsus  Bigeminus 

Two  beats  and  a  pause. 
There  is  also  a  Pulsus 
Trigeminus  (three  beats 
and  a  pause),  and  a 
Pulsus  Quadrigeminus. 
The  extra  beat  is  some- 
times due  to  an  extra 
systole. 

Epileptiform  Attacks 

Heart  Failure 

Mitral  Stenosis 

esp.  after  digitalis 

Neurasthenia 

It  also  occurs  after  great 
mental  or  bodily  strain. 

248-254 


PULSE 


97 


255.  Pulsus  Bisferiens 

The  summit  wave  and  tidal 
wave  are  felt  separately. 

*Aortic  Regurgitation  (x) 

„       Stenosis 
Hypertrophy  and  Dilatation 
of  Left  Ventricle 

256.  Pulsus  Paradoxus 

Smaller  and  less  frequent 
during  deep  inspiration. 

Acute  Laryngitis 
Adenoids 
Asthma 
Emphysema 
with  dilated  heart 

Enteric  Fever  (x) 
*Mediastinal  Growths 
*Mediastinitis 

Pericardial  Adhesions 
esp.  if  mediastinal 

Pericardial  Effusion  (x) 
Tracheal  Stenosis 

In  children  any  obstruction 
in  the  air  passages  will 
cause  it,  and  it  is  some- 
times physiological. 

257.  Riegel's  Pulse 

This  differs  from  pulsus 
paradoxus  in  that  the 
change  takes  place  with 
expiration  instead  of  inspi- 
ration. It  has  the  same 
significance. 

258.  Arrhythmia 

The  condition  when  ex- 
treme is  termed  delirium 
cordis. 

Pulse  irregular,  or  inter- 
mittent, or  both.  The 
auricular  systole,  as  shown 


in  pulsating  veins,  often 
takes  place  when  there 
is  no  ventricular  systole. 
In  general,  gross  irregu- 
larity is  more  serious  than 
intermittency. 

Adherent  Pericardium 
Aerophagia  nervosa 
Arterio-sclerosis    of    Left 
Coronary 

usually    every    third    beat 
dropped 

Aneurysm  of  Heart 

Aortic  Aneurysm 

Apoplexy,  Severe 

Arsenical-poisoning 

Auricular  Fibrillation  (259) 
*Cardiac  Breakdown 

Collapse  (235) 

Concussion  of  Brain,  hi., 
„  of    Spine 

Digitalis 

cumulative  action  of 

Dilatation  of  Heart 

Displacement  of  Heart 

Dyspepsia,  Flatulent 

Emphysema 
*Endocarditis,  Malignant 

Exophthalmic  Goitre 

Fatty       Degeneration       of 
Heart 

Fibroid  Heart 

Gangrene  of  Lung 

Gout,  Undeveloped 

Hypochondriasis 

Influenza 

Jaundice  (392) 

Lithaemia 

Lesion  of  Medulla 

Mitral  Regurgitation 

Myocarditis,  Acute 

Neurasthenia 

255-258 


98 


PULSE 


Arrhythmia — continued 
Neurosis  of  Heart 
(Edema  Laryngis 
Pericarditis 
Stokes-Adams'  Disease 

auricular    beat    regular ; 
ventricular  alternate 

Syphilitic  Heart 

Tuberculous  Meningitis,  in. 
Also  from  senility,  over 
work,  nervousness,  dis- 
tended stomach,  or  abuse 
of  tea  or  tobacco.  When 
the  arrhythmia  recurs 
regularly,  it  is  termed 
AUorhythmia. 

259.  Auricular  Fibrillation 

This  accounts  for  50  per 
cent,  of  all  cases  of  cardiac 
irregularity  (Price).  It 
may  be  suspected 
when,  late  in  the  course 
of  mitral  stenosis  or  car- 
diac sclerosis,  the  pulse 
becomes  irregular  and  the 
general  condition  graver, 
while  the  presystolic 
thrill  and  murmur  dis- 
appear. The  diagnosis 
must  be  confirmed  by  the 
Polygraph. 

Impending  Heart  Failure 
Fibrillation  also  takes  place 
when  adrenalin  is  injec- 
ted after  an  anaesthetic. 

260.  Dicrotic  Pulse 

Exaggeration  of  the  dicrotic 
wave.  It  is  sometimes 
mistaken  for  a  pulse  of 
twice  the  rate. 

Alcoholism 
*Enteric  Fever 
Erysipelas 
Hyperpyrexia 


Pericarditis 
Peritonitis,  Septic 
Pleurisy,  Acute,  in. 

Also  on  exposure  to  great 
heat. 

(See  Low  Tension,  273) 

261.  Anacrotic  Pulse 

The  tidal  wave  is  stronger 
than  the  summit  wave. 

Aortic  Stenosis 

262.  Weaker  on  one  Side 

Abnormal  distribution  of 
the  arteries  is  not  un- 
common. 

Aneurysm      of      Ascending 

Aorta 

right  side 
Aneurysm     of     Descending 

Arch 

left  side 
Aneurysm     of     Innominate 

Artery 

right  side 
Aneurysm     of     Subclavian, 
Axillary,  or  Brachial  Artery 

same  side 

Arteritis 

Cervical  Rib,  Unilateral 

stronger  when  the  arm  is 
raised 

Embolism    of    Brachial    or 
Radial  Artery- 
old  or  recent 

Hydrothorax 

Mediastinal  Tumour 

Pleural  Effusion,  Large 

Pneumothorax 

Tumour  of  Neck,  Chest  or 
Axilla 

258-262 


PULSE 


99 


263.  Weak  in  Posterior  Tibial 
Artery 
Abnormal  Distribution 
Aneurysm,  Abdominal 

„  Iliac 

Claudication  Intermittente 
Obliteration  of  Aorta 


264.  Later  in  Left  Radiai 

Aneurysm  between  Innomi- 
nate and  Left  Carotid 


265.  Late  in  both  Pulses 

Aortic  Regurgitation 


266.  Artery  Hard  and  Tortuous 

'  The  artery  feels  like  the 
stem  of  a  tortuous  clay 
pipe.' 

Alcoholism 

Aneurysm 

Gout 

Lead -poisoning 

Nephritis,  Chronic 

Progeria 

Senility 

Syphilis 

Tortuosity  and  hardening 
of  the  radials  do  not 
necessarily  indicate  the 
same  condition  in  the 
aorta. 


267.  Pulse-Respiration   Ratio 
Normally  4  to  1. 

Narcotic-poisoning 

6*  to  1 
Pneumonia,  Acute 

5  to  2 

268.  Pulse-Temperature  Ratio 

Lowered   —    'Relative 

Bradycardia  * 

The  puis 3  rate  ordinarily 
rises  8  or  9  beats  for 
every  degree  of  temper- 
ature. 

Abscess,  Cerebral 
Enteric  Fever 
Influenza 
Meningitis,  Acute,  n. 

,,  Tuberculous,  n. 

Relapsing  Fever 
Yellow  Fever 

269.  Venous  Pulse,  Centripetal 

Aneurysmal  Varix 
Dilated  Arterioles 

(See  Venous  Pulsation, 
283,  725) 

270.  Schapiro's   Test 

Normally,  the  pulse  rate 
is  lessened  by  7  to  15 
beats  per  minute  when 
a  patient  lies  down. 
When  no  diminution 
takes  place  there  is — 

Cardiac  Weakness 


H  2 


263-270 


100  ARTERIAL  TENSION 


271.  ARTERIAL  TENSION 

The  normal  systolic  pressure,  estimated  in  mm.  of  mercury 
is  about  90  under  fourteen  years  of  age  ;  100  to  115  up  to  twenty 
years  of  age,  while  from  twenty-one  to  sixty-five  it  is  usually 
120  to  135.  In  very  old  age  with  rigid  arteries  it  may  go  up 
to  200.  The  pressure  in  women  is  10  to  15  mm.  lower. 
It  is  low  in  children  and  in  adults  who  have  been  kept  in  bed. 
Digital  estimation  is  not  very  reliable,  but  the  sphygmometer 
is  not  without  its  fallacies,  and  results  must  be  received  with 
caution  when  the  artery  is  thickened,  the  skin  oedematous,  a 
superjacent  muscle  spastic,  or  the  subject  very  fat.  Gaertner's 
Finger  Tonometer  is  free  from  some  of  these  objections. 

The  tension  is  determined  by  the  sphygmometer,  usually 
Riva-Rocci's  or  Hill  and  Barnard's.  In  using  the  Riva-Rocci 
instrument,  the  armlet  is  fixed  securely  to  the  upper  arm  and 
the  pressure  gradually  raised  until  the  pulse  can  no  longer  be 
felt  at  the  wrist,  when  the  reading  is  taken.  As  a  check,  the 
reading  at  the  re-appearance  of  the  pulse,  when,  by  means 
of  the  valve,  the  pressure  is  gradually  relaxed,  should  also  be 
noticed. 

Diastolic  Pressure  is  that  which  corresponds  with  the  interval 
between  the  heart  beats.  It  depends  largely  upon  the  degree 
of  contraction  or  relaxation  of  the  arterioles,  and  is  best  ascer- 
tained by  the  auditory  method.  In  this,  the  stethoscope  is 
placed  below  the  armlet,  and  when  the  sounds  disappear  under  a 
falling  pressure,  the  number  of  mm.  Hg  is  read  off.  Normally 
it  is  about  100. 

Arterial  Tension  is  altered  physiologically  as  follows  : — 
Increased  by  : 

(a)  Muscular  or  mental  work  or  excitement. 

(b)  Increase  in  rate  and  power  of  heart  beat. 

(c)  Increase  in  the  quantity  of  blood  (e.g.  after  a  meal). 

(d)  Increase  in  the  contraction  of  the  arterioles  (e.g.  by  cold). 
Diminished  by  : 

Recumbent  position,  by  warmth,  and  by  diminution  in  (b), 
(c)  and  (d). 


271 


ARTERIAL   TENSION 


101 


272.  High  Tension 

Powerful    ventricular    con- 
traction with  contracted 
arterioles. 
Aneurysm  of  Aorta 

if    of    ascending     portion, 
unilateral. 
Angina,  Abdominal 

„         Pectoris 
Apoplexy,  Impending 
Arterio-sclerosis 
Bronchitis,  Chronic 
Cerebral  Tumour,  i. 
Cheyne-Stokes'  Breathing 
Cirrhosis  of  Kidney 

sometimes  over  300  mm. 
Constipation 
Cyanosis  (396) 
Dilatation  of  Aorta 
Emphysema 
Glycosuria,  Gouty 
Gout  (tj) 
Hemicrania 
Hypertrophy  of  Heart 
Hysterical  Seizure 
Lead-poisoning 
Locomotor  Ataxy 

during  crisis 
Malaria  (cold  stage) 
Melancholia 
Meningitis,  I. 
Migraine 
Mitral  Stenosis 
Pleurisy,  Acute,  I. 
Pregnancy 
Pseudo-Angina 
Rigor 

Toxaemia,  Chronic 
Viscosity  of  Blood  (1473) 
And    all    kidney  affections 
except  the  amyloid,  the 
suppurative,      and      the 
tuberculous. 
Further,  too  nitrogenous  or 
too  liquid  a  diet. 


273.  Low    Tension 

Heart  weak  and  arterioles 
dilated ;  dicrotism  well 
marked. 

Addison's  Disease 

Anaemia 

Aortic  Stenosis 

Asthma 

Chlorosis 

Cholera 

Debility 

Diabetes 

Diarrhoea 

Dilatation  of  Heart 

Dysentery 

Exhaustion 

Fatty       Degeneration       of 

Heart 
Fevers 

Fibroid  Heart 
Haemorrhage 
Jaundice  (392) 
Mitral  Regurgitation 
Neurasthenia 
Obesity 
Phthisis,  i. 
Pleurisy,  Acute,  u. 
Pyrexia  (295) 
Shock 
Syncope 
Thrombosis 
Trypanosomiasis 
Vomiting 

Generally  speaking,  it  occurs 
in  all  asthenic  conditions, 
but  it  is  also  produced  by 
dry  diet,  hot  air,  hot 
baths,  or  hot  drinks,  and 
by  the  action  of  chloral, 
cannabis  indica,  nitrite 
of  amyl,  nitroglycerin, 
nitrous  ether,  and  mistle- 
toe. 

272-273 


102 


ARTERIAL    TENSION 


274.  Grunbaum's  Test 

Suprarenal  extract  fails  to 
raise  arterial  tension. 

Addison's  Disease 


275.  Hertzel's  Sign 

When  the  circulation  in 
both  legs  and  one  arm  is 
completely  arrested  by- 
pneumatic    pressure,  the 


bloo  1     pressure    in     the 
remaining  arm  rises  about 


5  mm.  Hg. 

of    60     mm. 
place  in — 

Arterio-sclerosis 


But 
Hg 


a  rise 
takes 


(One  would  think  that  some 
risk  of  producing  apo- 
plexy might  be  incurred 
by  this  procedure.) 


274-275 


SPHYGMOORAPH 


103 


276.  THE  SPHYGMOGRAPH 


Summit   Wave 


Tidal   Wave. 

\  '■■% Dicrotic   Wave . 

^^>eX   4^  Wave 


Di  acjrammatic      SphygmogTayn 


Fig.  2. — The  Points  of  a  Sphycmogkam 

As  compared  with  the  pulse  felt  by  the  finger,  the  rise  of 
pressure  corresponds  with  the  '  line  of  ascent ' ;  the  duration  of 
pressure,  with  that  portion  of  the  line  ofjiescent  extending  from 
the  '  summit  wave  '  to  the  dicrotic  notch  ;  and  the  fall  of  pressure, 
from  the  dicrotic  wave  downwards. 


277.  LINE  OF  ASCENT 


Vertical 


Vigorous  heart-contractions 
or  relaxed  arterioles. 

Aortic  Regurgitation 


Oblique 

Weak     ventricular     con- 
tractions. 

Aortic  Stenosis 

Aneurysm 

proximal  side 

Mitral  Regurgitation 


High 

Easy  capillary  circulation. 
Aortic  Regurgitation 
Pyrexia 

Low 

Obstructed  peripheral  cir- 
culation, and  contraction 
of  muscular  coat. 

Aneurysm 

Mitral  Regurgitation 

Forked  or  Anacrotic 

High  Peripheral  Resistance 
as  in  Chronic  Nephritis 


276-277 


104 


SPHYGMOGRAPH 


Sharp 


278.  SUMMIT  OF  PERCUSSION  WAVE 
Blunt 


Vigorous  heart-contractions, 
easy  capillary  circulation, 
and  relaxed  muscular  coat 
— tension  low. 

Aortic  Regurgitation 


Weak  heart  -  contractions 
and  contracted  muscular 
coat — tension  high. 

Aneurysm 
proximal  side 

Aortic  Stenosis 
Arterio-sclerosis 


279.  TIDAL  WAVE 


Marked  (high  tension) 

Vigorous  heart-contractions 
and  obstructed  peripheral 
circulation. 

Aortic  Stenosis 
Arterio-sclerosis 

Faint 

Weak  heart  -  contractions, 
or,    if   strong,   associated 


with  over-full  arteries  ; 
easy  capillary  circulation 
and  relaxed  muscular 
coat. 

Aneurysm 
proximal  side 

Aortic  Regurgitation 
Mitral  Regurgitation 


280.  DICROTIC  WAVE 


Marked  (low  tension) 

Vigorous  heart-contractions, 
easy  capillary  circula- 
tion, and  relaxed  muscu- 
lar coat. 


of 


or 


Descending 
Abdominal 


Aneurysm 

Thoracic 

Aorta 
Pyrexia 
(See  Dicrotic  Pulse,  260) 


Faint  (high  tension) 

Weak  heart ;  or  strong 
heart  with  over-full  arte- 
ries, obstructed  peripheral 
circulation,  and  contrac- 
tion of  muscular  coat. 

Aneurysm 
proximal  side 

Aortic  Regurgitation 
late 

Arterio-sclerosis 
Mitral  Regurgitation 


281.  Line  of  Descent  Irregular 

Mitral  Regurgitation 
„     Stenosis 


282.  Base  Line  Undulating 

Dysprcea  due  to  affections 
of  the  medulla 

Tuberculous  Meningitis 
(See  Cheyne- Stokes'    Breath- 
ing, 1214) 

278-282 


SPHYGMOGRAPH 


105 


Normal  Pulse. 


Aortic  Regurgitation.  Mitral  Stenosis 


Aortic  Stenosis  Mitral  Regurgitation. 

Fig.  3. — Typical  Sphygmograms 

The  tracings  will  vary  according  to  the  degree  of  compensation. 


283.  VENOUS  PULSE 

This  must  be  studied  with  Mackenzie's  Polygraph.  One  of 
the  most  important  points  is  the  determination  of  the 
auricular  systole.  It  immediately  precedes  the  carotid 
wave,  and  the  radial  pulse  is  -^  second  later  than  this. 
See  259,  269,  725. 


283 


106 


PULSATION 


ABNORMAL  PULSATION 


284.  Chest 

To  detect  supra-sternal  pul- 
sation, it  may  be  neces- 
sary to  press  a  ringer 
firmly  down  behind  the 
sternum. 

Aneurysm 

pulsation  '  heaving  '  or  ex- 
pansile 

An  aneurysm  of  the  ascend- 
ing aorta  first  touches 
the  chest  wall  in  the 
second  right  space  near 
the  sternum  (rarely  to 
left) ;  of  transverse  arch, 
behind  manubrium ;  of 
descending  arch,  below 
first  left  rib  ;  of  innomi- 
nate artery,  behind  right 
sterno-clavicular  articu- 
lation. 

There  is  no  pulsation  when 
the  sac  is  solid. 

Aneurysm  'Mimic' 

A  transient,  fusiform  dilata- 
tion ;  u  seat,  abdominal 
aorta  or  subclavian  artery. 

Appendix,      Hypertrophied 
Left 

2nd  and  (x)  3rd  left  space 
— presystolic 

Bursting  of  an  Artery  into 

an  Abscess  Cavity 
Cancer  of  Pleura 
Cardiac  Aneurysm  (x) 
precordial 

Dilated  Aorta 

suprasternal  notch 
Dilated  Conus  Arteriosus 

2nd  left  space 

Dilated  Right  Auricle 

3rd,  4th,  and  5th  right 
spaces 


Displaced  Heart  or  Dextro- 
cardia 

2nd  to  5th  right  spaces 
Empyema  Necessitatis 
Empyema  Pulsating 

all  one  side 
Heart,  Uncovered 

from  retraction  of  lung 
Hypertrophy  and  Dilatation 

of  Right  Ventricle 

3rd,     4th,     5th,     and     6th 
spaces    near    left    sternal 
edge 
Mediastinal  Abscess 

above  or  at  side  of  sternum 
Mitral  Stenosis 

3rd  left  space 
Pleural  Effusion 

very  rarely 
Pulmonary  Artery,   Pulsat- 
ing 

2nd  and  3rd  left  spaces 
near  sternum 

Pulsating  Liver  (286) 

,,         Sarcoma 
Right    Subclavian,    Abnor- 
mal 

suprasternal  notch 
Tumour,  Mediastinal 

Pulsation  in  the  supra- 
sternal notch  is  found 
normally  in  thin  elderly 
persons  and  in  many 
neurotic  subjects. 

(See  Pulsating  Veins,  259, 
269,  725,  and  Tracheal 
Tug,  713) 


284 


PULSATION 


107 


285.  Abdominal  Pulsation 

Aneurysm 
Cancer 

Embolism  of  Common  Iliac 
♦Palpitating  Aorta 

lessened  when  patient 
leans  forward 

Tumours  (x) 

286.  Pulsating  Liver 
Aortic  Regurgitation 
Mitral  Stenosis 

♦Tricuspid  Regurgitation 

Pulsation  may  also  be  trans- 
mitted to  the  liver  by 
an  aneurysm  or  a  hyper- 
trophied  heart ;  but  in 
these  cases  it  is  not 
expansile. 

287.  Epigastric  Pulsation 

This  is  usually  synchronous 
with  the  heart's  systole. 
If  delayed  slightly  it  is 
probably  neurotic,  though 
it  may  be  due  to  an 
aneurysm. 

Anaemia 

Aneurysm  of  Aorta 
♦Aortic  Regurgitation 

Dilatation  of  Right  Ventricle 
diastolic 

Dilatation  of  Stomach 

Displacement   of    Heart    to 

Right 
♦Distension  of  Stomach 

Emphysema 

Haemorrhage 

Hepatic  Abscess 


Hypertrophy  of  Right  Ven- 
tricle 

Mitral  Regurgitation 
Stenosis 

Neurasthenia 

♦Palpitating  Aorta  or  Coeliac 
Axis 

Pancreas,  Enlarged 

Pericardial  Effusion 

Pleural  Effusion,  Left 

Pulmonary  Stenosis 

Pulsating  Liver  (28G) 

Short  Sternum 

Tricuspid  Regurgitation 

Tumour  resting  on  Aorta 


288.  Capillary    Pulsation 

Visible  in  the  nails ;  or  alter- 
natively on  a  patch  of 
erythema  produced  by 
drawing  a  line  across  the 
forehead  or  sternum  with 
the  thumb  nail. 

Anaemia  (x) 
Aortic  Regurgitation 
Chlorosis 

Haemorrhage,  Severe 
Heart-muscle  Failure 
Pernicious  Ansemia 


289.  Pulsation   Synchronous 
with  Respiration 

Hernia  Cerebri 

„  Pulnionalis 
Meningo-myelocele 
(See  Carotid  Throbbing,  721) 


285-289 


108 


TEMPERATURE 


290.  TEMPERATURE 


M.    E.M.  E.M.  E.  M.    EM.  E.M.  E.M.  E  M.  E.M.  EM.  E 


Fig.  4. — Types  of  Temperatures 
a,  continued ;    b,  remittent ;    C,  severe  or  septic  remittent. 

291.  To  take  the  temperature,  the  register  or  column  of 
mercury  must  be  first  shaken  down  to  97°.  The  thermometer 
bulb  should  then  be  placed  under  the  patient's  tongue,  and  the 
lips,  but  not  the  teeth,  closed.  After,  say  twice  the  time  for 
which  the  instrument  is  guaranteed,  it  must  be  withdrawn  very 
gradually  and  the  degree  noted.  Twice  a  day,  8  a.m.  and  8  p.m., 
is  sufficient  as  a  rule.  In  infectious  cases  a  special  thermometer 
should  be  used,  and  when  no  longer  required  it  must  be  sterilised 
by  thorough  washing,  followed  by  immersion  for  one  hour  in 
perchloride  of  mercury,  1  in  500  solution. 

In  children  the  fold  of  the  groin  with  the  thigh  flexed,  or  the 
rectum,  is  sometimes  preferable  to  the  mouth  ;  but  it  must  be 
remembered  that  muscular  exercise  will  raise  the  rectal 
temperature  to  101°  or  102°  even  in  health. 

It  is  noteworthy  that  some  individuals  and  some  families 
will  develop  a  high  temperature  from  very  slight  causes. 
In  others,  the  reverse  is  the  case. 

To  convert  the  Centigrade  into  the  Fahrenheit  scale  it  is 
useful  to  remember  that  35°  C.  equals  95°  F.,  and  that,  for  higher 

290-291 


TEMPERATURE 


109 


temperatures,  all  that  is  necessary  is  to  add  1*8°  F.  to  each 
degree  C.,  thus  : 


36°  C.  =  96-8°  F. 
37°  C.  =  98-6°  F. 
38°  C.    =  100-4°  F. 

292.  Subnormal 

It  is  often  betrayed  by  cold 
breath.  Low  temperature 
means  low  vitality. 

Abscess,  Cerebellar 
Addison's  Disease 
Alcoholic  Coma 
Anaesthesia,  Prolonged 
Arterio-sclerosis 
Asthma,  Spasmodic 
Cancer 

Carbolic-acid-poisoning 
Cerebellar  Tumour 
Cerebral  Haemorrhage 

,,       Tumour 
Cirrhosis  of  Kidneys 

,,        of  Lungs 
Caloral-poisoning 
*  Cholera,  Asiatic 

to  94°  or  less 
Cholera,  Sporadic 

to  96° 
Chorea  (x) 
Collapse  (235) 

„        of  Lungs 
Convalescence 

after  fever 
Cretinism 
Cyanosis 
Diabetes 

Diarrhoea,  Profuse 
Enteric  Fever 

mornings    only — 3rd   week 

also  a  sudden  fall  on  per- 
foration occurring 

^Haemorrhage 


39°  C.  = 
40°  C.  = 
41°  C.    = 


102-2°  F. 
104-0°  F. 
105-8°  F. 


Heart  Disease,  Chronic 
Intestinal  Obstruction 
Malformation  of  Heart 
Melancholia 
Myxcedema  (94°-98°) 
Neurasthenia 
Opium- poisoning 
Oxalic-acid-poisoning 
Peritonitis,  Tuberculous 
Phthisis 

morning  (x) 
Pituitary  Tumours 
Pneumonia,  Acute 

after  crisis  (x) 
Relapsing  Fever 
defervescence 
*Sclerema  neonatorum 
sometimes  to  70° 
Septic-poisoning 

morning 
Shock 
Starvation 
Trance 
Trypanosomiasis 

at  intervals 
Tuberculous   Meningitis   (x) 
Uraemic  Attack  (x) 
Valvular  Diseases 
***  Also  antipyretic  drugs,  cold 
sponging,    and   poisoning 
by      depressants.        Ex- 
treme external  cold  will 
lower  the  body  tempera- 
ture.      In      Shackleton's 
expedition,       when      the 
external  temperature  was 
-30°   to    -40°    F.,    the 
body    registered    93°    F. 

291-292 


110 


TEMPERATURE 


293.  Local  Lowering 

Aura  epileptica 

one  extremity 
Cerebral  Haemorrhage,  n. 

paralysed  side 
Chronic    Atrophic    Spinal 

Paralysis 
Compression  of  Cord 
*Cyanosis 
Hysterical  (Edema 
Locomotor  Ataxy 
Paralysed  Limb 
Scleroderma 
Spinal  Apoplexy 

limbs 
Spinal  Paralysis  of  Adults, 

Acute 
Syringomyelia 
Transverse  Softening  of  Cord 
(See  Cold   Extremities,  870) 

294.  Local  Rise 

Local       inflammation       in 
general. 

*Abscess 
Boil 

Carbuncle 
Convulsions,  Unilateral 

affected  side 
Corpus  striatum,  Lesion  of 

paralysed  side 

Gout 

Pneumonia 

Pulmonary  Tuberculosis 

0*4    in    axilla   of    affected 
side 

Osteitis  Deformans 

great  rise  on  affected  side 

Suppuration 

Synovitis 


Traumatic  Neurasthenia 

vertex 

Vaso-motor  Paralysis 

***  The  temperature  of  the 
urine  in  inflammatory 
bladder  affections  is  said 
to  be  higher  than  that  in 
the  rectum. 

295.  Raised,    Markedly 

T.  over  102°. 

All  inflammatory  diseases 
and  the  acute  exanthe- 
mata. 

Abscess,  Acute 
Ague 

cold  stage,  100°-101°  ;  hot 
stage,  105° 

Appendicitis 

Aortitis,  Acute 

Bell's  Mania,  n. 

Bronchitis,  Acute 

Broncho-pneumonia 

Bruhl's  Disease 

Cancrum  Oris 

Cerebro -spinal  Meningitis 

Cystitis 

Dengue 

Dentition 

Diphtheria 

Dysentery 

Empyema 

Encephalitis 

Endocarditis,  Acute 

Enteritis,  Acute 

Erysipelas 

Extravasation  of  Urine 

Eebricula 

Gastritis,     Erythematous, 

Acute 
Glanders 
Glandular  Fever 

293-295 


TEMPERATURE 


111 


Raised,      Markedly  —  con- 
tinued 

Glaucoma,  Acute 

Glossitis 

Gout 

Hepatic  Abscess 

Hepatitis,  Acute 

Herpes  Pharyngis 

Hooping-Cough 
invasion 

Hydrocephalus,  Spurious 

Hysteria  (x) 

Hystero-epilepsy 
seizure 

Infantile  Paralysis 
onset  102°-103° 

Influenza 

Labyrinthitis,  Acute 

Mania 

Measles 

Mediastinal  Abscess 

Meningitis,  Cerebro- spinal 
„  Simple 

,,  Spinal 

Milroy's  Disease 
crisis 

Mumps 

Myelitis,  Acute 

Myocarditis,  Acute 

Nephritis,  Acute 

Oophoritis 

Ophthalmia 

Orchitis 

Otitis  Media,  Acute 

Pancreatitis,  Acute 

Peliosis  Rheumatica 

Pelvic  Abscess 
„     Cellulitis 
„      Peritonitis 

Periarteritis  nodosa 

Pericarditis 


Perihepatitis 
Perinephritis 
Periproctitis 
Peritonitis,  Acute 
very  rarely  normal 

Phlebitis,  Acute 

Phlegmasia  Dolens 

Phosphorus-poisoning,  Acute 

Phthisis 

Plague,  ii. 

Pleurisy,  Acute 

Pneumonia,  Acute 

Polymyositis 

Post-pharyngeal  Abscess 

Psittacosis 

Puerperal  Septicaemia 

Pyelitis,  Acute 

Quinsy 

Relapsing  Fever 

Remittent  Fever 

Renal  Embolism 

Rheumatism,  Acute 

„  Gonorrhceal 

Roseola 
Rotheln 
Scarlatina 

Spinal  Concussion,  n. 
Splenitis 
Syphilitic  Lung 
Tabes  mesenterica 
Tetanus 
Tetany 

in  severe  paroxysms 

Tonsillitis 
Trichinosis 
Tuberculosis,  Acute 
Typhic  State  (62) 
Typhus 

Urticaria  Febrilis 
Vaccinia 
Varicella 

295 


112 


TEMPERATURE 


Raised,     Markedly  —  con- 
tinued 
Variola,  I.,  in. 
Weil's  Disease 
Woillez's  Disease 
Yellow  Atrophy,  Acute 
Fever 


296.  Raised,  Slightly  or  Incon- 
stantly 
Between  99°  and  102°  F. 

Addison's  Disease 
Apoplexy,  u. 
Appendicitis 
Bacilluria 
Bronchiectasis 
Cancer  of  Liver 
Cirrhosis  of  Liver,   Hyper- 
trophic 
of  Lung 
Convulsions,  Following 
Coryza 

Diarrhoea,  Irritative 
Dietl's  Crisis 

Erythema  Scarlatiniforme 
Exophthalmic  Goitre 
Gonorrhoea 
Haeniophilic  Arthritis 
Haemorrhage 
also  premonitory 

Hay  Asthma 

Hepatic  Colic 

Herpes  Zoster 

Hydrophobia 

Hyperaemia  of  Lungs,  Acute 

Hysteria  (x) 

Infantile  Hemiplegia 

Laryngitis,  Acute 

„  Spasmodic 

Leukaemia 


Lymphadenoma 
esp.  in  the  young 

Meningitis,  Tuberculous 

Metritis 

Mollities  Ossium 

Myelosarcoma 

Paralysis,  Acute  Ascending 

onset 
Peritonitis,  Chronic 
Pernicious  Anaemia 
Phthisis,  i. 
Pyrexia 
Renal  Calculus 
Sarcoma  (x) 
Syphilitic  Eruptions 
Variola,  n. 

The  temperature  may  be 
raised  by  exercise,  excite- 
ment, the  use  of  bella- 
donna, and  in  children  by 
food  containing  an  excess 
of  carbohydrates.  The  t 
passage  of  a  catheter  may 
produce  a  '  reflex  fever.' 


297.  Hyperpyrexia  (temp.  106° 

and  upwards) 

Occurs  occasionally  in  the 
following  diseases  and 
commonly  in  the  final 
stage  of  all  brain  affec- 
tions, the  temperature 
sometimes  rising  still 
more  after  death. 

Burns 

Cerebral  Haemorrhage 

esp.  into  upper  part  of  pons 
or  into  one  optic  thalamus 

Cerebral  Tumour  or  Abscess 

Dysentery 

Enteric  Fever 

Erysipelas 

Fractured  Skull 

295-297 


TEMPERATURE 


113 


Hyperpyrexia — continued 
Fractured  Spine 
Hysteria  (x) 

sometimes  incredibly  high 
without  any  constitutional 
disturbance 

Influenza 
♦Injury  to  Cord 
cervical  portion 

Intermittent,  Severe 

Malaria 

Meningitis,  Post  Basal 
transient  pyrexial  crises 

Meningitis,  Tuberculous,  in. 

Myelitis,  Traumatic 

Pachymeningitis,     Purulent 

Spinal 
♦Pneumonia,  Acute 

Pyrexia,  Neurotic 

Relapsing  Fever 

Remittent  Fever 
♦Rheumatism,  Acute 

Scarlatina 

Septicaemia 
♦Sunstroke 

Tetanus 

Tumour  of  Pons 

Uraemia 

Yellow  Atrophy,  Acute 
Fever 


298.  Remittent  Type,  or  Morn- 
ing Fall 

When  the  remission,  while 
never  reaching  the  normal 
point,  is  of  about  1°  or 
\\°  the  expression  '  con- 
tinued fever  '  is  employed, 
but  the  term  is  used  with 
little  precision. 

Appendicitis 
Broncho-pneumonia 


Cirrhosis  of  Lung 
Empyema 

Endocarditis,  Ulcerative 
♦Enteric  Fever 
Hepatic  Colic 
Kala  Azar 
Leukaemia 
Malta  Fever 
Mollities  Ossium 
Paratyphoid 
Phthisis,  m. 
Pleurisy,  Tuberculous 
Pyaemia 

Relapsing  Fever 
Remittent  Fever 
Rheumatism,  Acute 
Septic  Pneumonia 
Septicaemia 
Trichinosis 
Trypanosomiasis,  n. 
Tuberculosis 

299.  Septic  Remittent  or  Hectic 
Fever 

A  high  evening  temperature 
and  a  low  or  even  sub- 
normal morning  tempera- 
ture. The  term  inter- 
mittent should  not  be 
employed  for  this  type. 

Abscess,  Mediastinal 
„         Tuberculous 

esp.  in  bones 
Actinomycosis,  Pulmonary 
Cholangitis,  Suppurative 
Dysentery,  Chronic 
Empyema 
Endocarditis,  Septic 
Enteric  Fever 

3rd  week 
Hepatic  Abscess 
Hydatids,  Suppurating 
i  297-299 


114 


TEMPERATURE 


Septic  Remittent  or  Hectic 
Fever — continued 
Malta  Fever,  in. 
Otitis  Media,  Suppurative 
Peritonitis,  Chronic  (x) 
♦Phthisis,  in. 
Portal  Pyaemia 
♦Puerperal  Fever 
Pyaemia 

Pyelitis,  Chronic 
Pyonephrosis 
Septicaemia 
Sphenoidal  Sinusitis 
Tabes  mesenterica 
Thrombosis,  Sinus 
Tuberculosis,  Acute  Miliary 
Tuberculous    Ulceration    of 

Intestines 
♦Typhic  State  (62) 

This  type  of  temperature 
means,  in  general,  septic 
infection. 

300.  Inverse  Remittent  (High 
Morning  Temperature) 

Dentition 
Enteric  Fever  (x) 
♦Lobular  Pneumonia 
Tuberculosis 

301.  Intermittent  Type 
Apyrexial      intervals      not 

limited  to  the  morning. 
When,  in  Ague,  alternate 
days  are  free  from  fever, 
the  type  is  termed  '  ter- 
tian '  ;  when  two  clear 
days  intervene, '  quartan.' 
When  occurring  in  con- 
nection with  liver  or 
kidney  affections,  it  is 
termed  Hepatic  or  Renal 
Intermittent  Fever. 

Abscess,  Hepatic 


Abscess,  Pyaemic 
Calculus,  Hepatic 

„         Renal 
Cancer  of  Liver  (x) 
Colitis,  Mucous 
Leukaemia 
Liver,  Syphilitic  (x) 
Lymphadenoma 

5  to  15  days'  interval 
Lymphosarcomatosis 
♦Malaria  in  general 
Pernicious  Intermittent 
Pyelitis 

Pylephlebitis,  Suppurative 
Relapsing  Fever 
Trypanosomiasis 

302.  Spiked  Chart 

Periodic     rises     lasting    24 
hours  each. 

Post  Basal  Meningitis 

303.  Termination  by  Crisis 

Sudden  fall  of  temperature. 

Erysipelas 
Measles 

Paratyphoid  (x) 
♦Pneumonia,  Acute 
Relapsing  Fever 
Typhus 

304.  Termination   by   Lysis 

Gradual  fall  of  temperature. 
Aspergillosis 
♦Enteric  Fever 
♦Lobular  Pneumonia 
Pleurisy 
Psittacosis 
Rheumatism,  Acute 
Weil's  Disease 

And  most  febrile  diseases. 
299-304 


tf,mim:ratitre 


iir, 


305.  Sudden  Invasion 
Endocarditis,  Ulcerative 
Erysipelas 
Gastroenteritis 
Influenza 

Malaria 
Mastoiditis 
( Osteomyelitis 
Otitis  Media 
•Pneumonia,  Acute 
Pyaemia 
Scarlatina 
Suppuration 
Tonsillitis 

(See  Sudden  Onset,  40) 

306.  Differential  and  Special 
Enteric  Fever 

1st  week  gradual  rise  to 
about  104°  -with  daily 
remission  of  2°. 

2nd  week  stationary,  daily 
remission  1°  to  1*5°. 

3rd  week  stationary,  daily 
remission  3C  to  5°. 

4th  week  gradual  return  to 
normal  temperature  with 
remissions  of  1°  to  1*5°. 

Lymph  adenoma 

Remittent  with  a  fortnight's 
afebrile  interval. 

Meningitis,  Simple 

usually  over  102°,  irregular 


Meningitis,  Tuberculous 

about  100°,  rarely  over  102° 
until  approach  <>f  death 

P.  hie  Cellulitis 

under  102° 
Pelvic  Peritonitis 

over  102° 
Pneumonia,  Acute 

103°  to  105°  ;  morning  re- 
missions absent  or  slight 

Relapsing  Fever 

The  rise  to  104°  on  the  first 
day  lasts  a  week  ;  then 
comes  an  apyrexial  inter- 
val followed  by  three  days 
of  fever.  Other  relapses 
may  ensue. 

Scarlatina 

High  the  first  four  days,  then 
a  partial  subsidence.  Not 
normal  till  end  of  second 
week. 

Typhus 

1st  week  104°  to  106°,  then 

one  day's  remission. 
2nd  week,  still  higher. 

Varicella 

Usually  slight,  but  recurring 
with  each  crop  of  vesicles. 

Variola 

A  fall  on  appearance  of  rash 
and  a  second  rise  when 
pustulation  begins. 


i  2 


305-306 


116  NUTRITION 


307.  STATE  OF  NUTRITION 

The  patient  may  be  described  roughly  as  well  or  ill  nourished, 
but  for  exact  results  he  should  be  weighed  and  measured,  and 
the  result  compared  with  Hutchinson's  Table.  It  is  almost 
impossible  to  carry  this  table  in  one's  head.  I  have  therefore 
devised  the  following  formula,  which  gives  almost  identical 
results  :  The  weight  of  a  person  5  ft.  high  should  be  115  lb.  For 
every  additional  inch  of  stature  add  5  lb.  Thus  for  6  ft.  it  would  be 
115+60  (5x  12)=  175  ;  a  margin  of  20  per  cent,  either  way  is 
consistent  with  health.  The  full  weight  must  not  be  expected 
in  the  immature.  In  the  case  of  infants  the  weight  for  the 
first  month  may  be  taken  as  7  lb.  At  six  months  this  should  be 
doubled,  and  at  thirteen  months  trebled.  At  the  end  of  the 
second  year  the  weight  should  be  30  lb.  ;  of  third,  34  lb.  ;  of 
fourth,  38  lb.,  and  of  fifth  year,  42  lb. 

At  six  years  of  age  a  boy  should  weigh  50  lb.  and  a  girl 
40  lb.,  and  both  should  add  5  lb.  for  every  year  of  age  up  till  ten. 
Between  ten  and  sixteen  the  girl  grows  faster  than  the  boy  ;  but 
after  sixteen  the  boy  soon  passes  her.  During  the  first  year  of 
life  an  infant  should  grow  8  inches.  At  three  years  of  age  it 
should  be  half  its  adult  height.  The  average  annual  growth 
from  five  to  sixteen  years  of  age  is  two  inches.  The  body  weight 
is  least  before  breakfast. 

In  the  writer's  opinion,  too  much  importance  is  attached 
by  Insurance  Offices  to  the  Weight  for  Age  Table.  The 
majority  of  those  who  attain  a  great  age  are  of  spare  build, 
and  some  of  the  strongest  men  are  of  the  wiry  type.  There 
is  too  the  fallacy  of  length  of  limb.  Many  a  man  fails  to 
come  up  to  the  standard  because  he  happens  to  have  long 
legs ;  while  others  are  pronounced  to  be  too  heavy  for  their 
height  because  they  are  endowed  with  immense  limbs.  The 
real  test  of  standard  nutrition  is  the  formation  and  nutrition 
of  the  trunk,  and  the  proper  basis  of  a  table  should  be  the 
chest  measurement  as  compared  with  the  measurement  from 
the  tip  of  the  coccyx  to  the  vertebra  prominens.  This  ratio 
should  be  about  8  to  5.      (See  1204.) 

307 


NUTRITION 


117 


308.  Development  of  Fat 

♦Alcoholism 

♦Cessation  of  Active  Habits 
or  Occupation 

Chlorosis 

Cretinism 

Dementia 

Encephalitis  (x) 

Hypopituitarism 

buttocks,      abdomen,      and 
genitals 

Lipodystrophia 

lower  linibs  and  buttocks 
Lipomatosis  neurotica 
♦Menopause 
Mitral  Disease 
Myxoedema 

Pseudo-hypertrophic    Para- 
lysis 
Rickets 

Sclerosis,  Disseminated 
Tumour,  Cerebellar 

„        of  Pineal  Gland 

309.  Local  Muscular  Wasting 

or  Atrophy 

The  cause  may  He  in  muscle, 
nerve  or  nucleus. 

Amyotrophic    Lateral   Scle- 
rosis 
hand,  etc. 

Anterior  Crural  Paralysis 
quadriceps 

Arsenical  Neuritis 
Arthritis,  Gonorrhceal 
,,  Tuberculous 

Beri-beri 
Bulbar  Paralysis 

tongue,    lips,     and     (later) 
limbs 

Callus,  Pressure  of 


Cervical  Rib 

hand  and  arm 
Circumflex  Paralysis 

deltoid 

Compression  of  Cord 
Congenital  Asymmetry 
one-sided 

Disuse 

Duchenne's  Infantile 

Paralysis 

begins  in  face 
Elbow  Joint  Disease 

upper  arm 
Erb's  Paralysis 

begins  in  shoulder  girdle 
Facial  Paralysis 

nuclear  or  intranuclear 
Growths 

when  pressing  on  a  nerve 
Hereditary  Muscular  Atro- 
phy 

shoulders,  arms,  thighs,  and 
feet 

Hip  Disease 

Idiopathic   Muscular   Atro- 
phy 

including  face 

♦Infantile  Paralysis 
Injury  to  Motor  Nerve 
Knee-Joint  Disease 
esp.  in  thighs 

Landouzy  -  Dejerine     Para- 
lysis 

begins  in  face  and  extends 
to  shoulder  and  arm 

Lead  Palsy 

Long  Thoracic  Neuritis 

serratus  magnus 

308-309 


118 


NUTRITION 


Local  Muscular  Wasting  or 
Atrophy — continued 
Median  Neuritis 
pronators 

Mercurialism 
Morvan's  disease 
Motor  Neuritis,  n. 

of  muscle  supplied 
Musculo-spiral  Neuritis 

supinators 
Myelitis,  Acute 

esp.  when  in  lumbar  enlarge- 
ment 

Osteo-arthritis 
Paralysis  agitans 

hand 
■"Peripheral       Paralysis       in 

general 

very  rapid 
Phthisis 

about  shoulder  muscles 
Poliomyelitis,  Anterior 
Polymyositis 

muscles  firm 
Progressive   Muscular  Atro- 
phy 

'  main-en-griffe.'  Ball  of 
thumb  first.  Legs  first 
in  infantile  form. 

Pseudo-hypertrophic    Para- 
lysis 

of  latissimus  dorsi  and 
sternal  end  of  pectoralis 
major 

Rheumatism,  Old 
Rheumatoid  Arthritis 
Sciatica,  Old 
Spinal  Apoplexy 

,,       Paralysis   of   Adults, 

Acute 


Spinal     Paralysis,     Chronic 
Atrophic 

,,       Tumour 
Syringomyelia 

hand  first 

Tooth's  Paralysis 

'  bottle  thighs ' 
Tuberculous  Joint 

of  muscles  near  it 
Ulnar  Neuritis 

hypothenar 

310.  Muscular  Prominence 

without  increased  strength 
Pseudo -Hypertrophic   Para- 
lysis 
Thomsen's  Disease 

311.  General      Wasting      and 

Cachexia 

Children  get  thin  normally 
when  they  reach  the  rest- 
less age  of  four. 

*  Addison's  Disease 

Alcoholism,  Chronic 

Anaemia 

Ankylostomiasis 

Anorexia  Nervosa 
,,        Simplex 

Aspergillosis 

Bacteriuria 

Bilharzia 

Bronchiectasis 

Bronchorrhcea 
*Carcinoma 

Cholangitis,  Chronic  Fibrous 

Cholera 

Cirrhosis  of  Liver 
„  of  Lung 
„      of  Stomach 

Coeliac  Disease 

309-311 


NUTRITION 


119 


General       Wasting       and 
Cachexia — continued 
Colon,  Idiopathic  Dilatation 
Constipation,  Habitual 
♦Diabetes 

„  '  Phosphatic ' 

Diarrhoea 

esp.  in  infants 
Dilatation  of  Stomach 
Duodenal  Catarrh 
Dysentery 

♦Dyspepsia,  Carbohydrate 
Empyema 
Enteritis 

Exanthemata,  The 
♦Exophthalmic  Goitre 
Gastritis,  Chronic 
Growth,  Rapid 
Haemorrhages 
Hydatids 
Infantile  Scurvy 
Intrathoracic  Tumours 
if  obstructing  thoracic  duct 

Jaundice 
♦Lactation,  Prolonged 

Lead-poisoning 

Leukaemia 

Lipodystrophia 
upper  half 
♦Locomotor  Ataxy 

Lymphadenoma 

Malaria 

Marasmus  Infantum 

Measles 

even  from  3rd  day  of  incu- 
bation (Meunier's  Sign)  j 


Melancholia 

Meningitis 

Menopause 

chiefly  in   fat  women  who 
were  thin  as  girls 

Mitral  Disease 

in  children 
Mollities  Ossium 
Morphinism 
Multiple  Myeloma 
Myelitis,  n. 
(Esophageal  Stenosis 
Ovarian  Cyst 
Overfeeding 

infants 
Pancreatic  Disease 
Pellagra 
Pelvic  Abscess 
Peritonitis,  Tuberculous 
Pernicious  Anaemia 
♦Phthisis 
Progeria 

Pyloric  Obstruction 
Relapsing  Fever 
Scurvy 

Spondylose  Rhizomelique 
Suppuration,  Chronic 
Suprarenal  Tumour 
Sprue 
Syphilis,  Hereditary 

„  Tertiary 

Tabes  Mesenterica 
Thyroidism 
Trypanosomiasis 
Tuberculosis,  Acute 
Worms 


311 


120 


NUTRITION 


312.  STATURE 


High 

Acromegaly 

Gigantism 
Low 

Achondroplasia 
'  dachshund  type ' 

Anosteoplasia 

Ateleiosis 

Cretinism 

Dwarfism,  Cerebral 
esp.  idiocy 

Fragilitas  Ossium 


Infantilism 
Leontiasis  Osssa 
Mongolian  Idiocy 
Osteitis  Deformans 
Osteo-malacia 
Pancreatic  Insufficience 
Phocomelus,  Congenital 
'  seal-like ' 

Progeria 

Rickets 

Spinal  Curvature 

Splenomegaly 


312 


SKIN 


121 


313.  THE  SKIN 

The  presence  of  oedema  is  ascertained  by  making  a  depression 
with  the  end  of  one  finger,  and  immediately  afterwards  brushing 
the  pulps  of  the  other  fingers  across  it.  If  the  depression  is  still 
palpable,  there  is  oedema.  Dermatographia,  which  includes 
tache  cerebrale,  is  elicited  by  drawing  a  line  with  the  back  of 
the  nail  across  the  skin  ;  after  a  few  seconds  a  red  streak  should 
appear  and  remain  visible  for  about  half  a  minute  ;  in  the  case 
of  urticaria,  a  wheal  may  follow.  A  chronic  unhealthy  flush, 
such  as  patients  commonly  complain  of  as  being  no  guide  to 
their  condition,  may  usually  be  distinguished  from  a  healthy 
colour  by  the  presence  of  twigs  of  dilated  arterioles  and  venules. 
Self-induced  skin  affections  always  occur  within  reach  of  the 
right  hand. 

Ringworm.  To  show  the  mycelium  in  the  scales,  wash  with 
ether,  drop  some  liquor  potassae  on  them,  and  after  a  quarter  of 
an  hour  put  the  cover-glass  on.  To  stain  the  spores  in  the  hair, 
first  wash  with  ether,  then  steep  for  twenty  minutes  in  a  saturated 
solution  of  gentian  violet  in  aniline  water,  and  for  two  minutes 
in  Gram's  iodine  solution.  Dry  with  blotting  paper  and  add  a 
drop  of  aniline  oil  which  has  been  coloured  mahogany  with 
iodine.  The  small-spored  variety  stains  more  rapidly  than  the 
large.     (See  also  356.) 


314.  Dry  Skin  (Anidrosis) 

Ague  (hot  stage) 

Anasarca 

Ascites 

Atrophy,  Senile 

Cretinism 

Compression  of  Cord,  Slow 
*Diabetes 
*Dysidrosis 

Enteric  Fever 

Gout 
during  attack 

Ichthyosis 

Influenza 

Kidney,  Cirrhosis  of 


Melancholia 

Myxcedema 

Perinephritis 

Peritonitis,  Chronic 

Prurigo 

Psoriasis 

Rheumatoid  Arthritis 

except  hands 

Sclerodermia 

Scurvy 

Sympathetic,  Paralysis  of 

affected  side  of  face 

Syringomyelia 
affected  limb 

313-314 


122 


SKIN 


Dry   Skin   (Anidrosis) — con- 
tinued 
Trypanosomiasis 
Tumour  of  Brain 
Xeroderma 
***  A  dry  skin  is  the  normal 
condition  in  many  persons. 

315.  Clammy  Skin 

Alcoholic  Coma 
*  Angina  Pectoris 

Arsenic-poisoning 

Arterio-sclerosis 

Colic 
*Collapse  (235) 

Delirium  Tremens 

Hepatic  Colic 

Intestinal  Obstruction 

Lead-poisoning 

Meniere's  Disease 

Rheumatoid  Arthritis 
hands 
*Shock 

Sunstroke 
*Syncope 

Thrombosis,  Cerebral 

316.  General  Sweating 
*Ague,  in. 

Apoplexy 

Bronchiectasis 
night 

Broncho  -pneumonia 

Debility 
*Defervescence 
*Diaphoretics 

Dilated  Stomach 

Dropsy,  Cardiac 

Emotions 

Epilepsy 

Exophthalmic  Goitre 


Fatty  Degeneration  of  Heart 
Gallstones 
Glanders 
Gout,  ii. 
Hectic 

Hydatid  of  Lung 
night 

*Influenza 

Phthisis 

night 

Pneumonia 
Polymyositis 
Pulmonary  Osteoarthro- 
pathy 
*Pyaemia 

intermittent 

Pyonephrosis 
Relapsing  Fever 
Remittent  Fever 
Renal  Colic 
*Rheumatism,  Acute 
continuous — acid 

Septicaemia 
Spinal  Appolexy 
Trichinosis 
Tuberculosis 

317.  Partial  Sweating 

Bromidrosis 

feet  and  axillae 
Facial  Hemihypertrophy 
affected  side 

Hemiplegia  (x) 

unilateral 
Intrathoracic  Aneurysm   or 

Tumour 

side  of  face 
Masturbation 

palms 

314-317 


SKIN 


123 


Partial       Sweating  —  con- 
tinued 
Migraine 

unilateral 
Multiple  Neuritis 

affected  parts 
Rickets 

head 
Suppurative  Parotitis 

unilateral 
Sympathetic,  Paralysis  of 

sound  side 
Syringomyelia 

hemihyperidrosis  (x) 

Irritating  smells,  such  as 
that  of  mustard,  induce 
facial  sweating  and  help 
in  the  diagnosis  of  para- 
lysis of  the  sympathetic 
nerve. 

318.  Chyloserous  Sweat 

Chyluria  (rare) 

319.  Bloody    Sweat     (Haemi- 
drosis) 

General  Paralysis  of  Insane 
Hysteria 

Menstruation,  Vicarious 
Rupture  of  Capillaries  into 

Sweat  Ducts 
Self-inflicted  Punctures 

320.  Coloured  Sweat  (Chromi- 

drosis) 

It  is  usually  local  and  occurs 
mostly  in  neurotic  young 
women. 

Blue 

B.  pyocyaneus  or  indigo  in 
sweat ;  copper  internally. 


Green 

iron  internally 
Red 

bacteria 
Yellow 

jaundice 

321.  Abnormal  Constituents  of 
Sweat 

Albumen 

Acute  Rheumatism 
Bile  Pigment 

Jaundice 
Cystin 

Cystinuria 
Dextrose 

Diabetes 
Lactic  Acid 

Lactation 

Puerperal  Fever 

Rickets  (x) 

Tuberculosis  (x) 
Urates  and  Oxalates 

Gout 

322.  Odorous  Sweat 

Addison's  Disease 

negro  -like 
Bacteriuria 

B.  coli — fishy 
Cholera 

urinous 
Favus 

mousy 
Glanders 

sour 
Hepatic  Abscess 

liverish 
Jaundice 

musky 

317-322 


124 


SKIN 


Odorous  Sweat — continued 
Measles 

like  freshly- plucked  feathers 
Osmidrosis 

cheesy 
Peritonitis 

musky 
Rheumatism,  Acute 

sour 
Scarlatina 

like  new  bread 
Scurvy 

offensive 
Typhus 

like  rotten  straw 
Uraemia 

ammoniacal  or  urinous 
Variola 

greasy 

Sulphur  taken  internally 
makes  the  sweat  smell 
like  H2S. 

Foul  sweat  is  sometimes 
due  to  a  growth  of  B. 
foetidus. 

Itching  (see  218) 

Pallid  Skin  (see  Face,  385) 

323.  Yellow  Skin 

Anaemia  of  dark  persons 
Bruises,  in. 
Chlorosis 
*Haemorrhage 
*  Jaundice  (392) 
Paroxysmal      Haemoglobin- 

uria 
*Pernicious  Anaemia 
lemon 
Xanthelasma 
esp.  eyelids 


Yellow  Fever 

***  Yellow  palms  are  said  to  be 
common  in  enteric  fever, 
but  they  also  occur  in 
functional  livei  affections. 
Picric  acid  and  nitric  acid 
stain  the  skin  yellow. 

324.  Pigmented    or    Bronzed 
Patches 
Abdominal  Tumours  (x) 
Acanthosis  Nigricans 

wart-like 
*  Addison's  Disease 
Arsenic-poisoning 

'  blue  bottom  ' 
Cancerous  Cachexia 
Chloasma 
Chromidrosis 

soluble  in  ether 
Cirrhosis  of  Liver 
Cocainism 

of  pricks 
Diabetes,  Bronzed 
Exophthalmic  Goitre 

earliest  in  eyelids 
*Freckles 
Haenioch  r  omatosis 
Haemoglobinuria,  Infantile 
Kidney,  Contracted  (x) 
Lepra  Anaesthetica 
Leprosy,  Nodular 
Lymphadenoma 
Malarial  Cachexia 
Melano-leucodermia 
Melanotic  Sarcoma 
Morphea 
Naevus 
Ochronosis 
Pediculosis 

or  bluish  ('  taches  bleuativs') 

Pellagra,  n. 
diffused  and  rough 

322-324 


SKIN 


12/1 


Pigmented        or        Bronze 
Patches — continued 

Pernicious  Anamiia 

Polycythemia,      Splenome- 

Pregnancy  [galic 

('  masque    des    femmes 
enceintes ') 

Recklinghausen's  Disease 

Rheumatoid  Arthritis 

Scurvy 

Still's  Disease 

Syphilide,  Pigmentary 

Tinea  Versicolor 

Tuberculosis,  Abdominal 

Urticaria  Pigmentosa 

Uterine  Irritation 

Vagabond's  Disease 

Xeroderma  Pigmentosum 
*+*  Also  from  intermittent 
pressure  (garters,  collar- 
stud,  etc.),  from  the  use 
of  vesicants  or  oil  of  cade, 
and  from  exposure  to  the 
electric  arc  light  or  to 
heat. 

Grey  Skin  (See  Face,  389) 

325.  Dermatographia      Rubra 

Elicited    by    drawing    the 
back  of  the  thumb  nail 
along    the    skin    of    the 
abdomen 
General  Paralysis 
Int.  Spinal  Meningitis 
Tuberculous  Meningitis 
Typhic  State  (62) 
Urticaria 

wheals  in  line 

And  most  cerebral  disorders 
(<  Tache  Cerebrale'). 
*#*  If  a  lasting  red  patch  is 
produced  by  friction  over 
a  painful  area,  the  pain  is 
probably  '  referred  '  from 
a  neighbouring  viscus. 


326.  Dermatographia  Alba 
(Sergent's  White  Line) 

The  line  is  produced  as  in 
tache  cerebrale.  It  ap- 
pears in  from  half  to  one 
minute  and  lasts  2  to  5 
minutes.  It  disappears 
when  adrenalin  is  injected 
and  therefore  indicates 
suprarenal  inadequacy. 

Addison's  Disease 
Fevers,  Specific 
esp.  scarlatina 

Influenza 
Locomotor  Ataxy 
Poisoning  by  Corrosive  Sub- 
limate 
Septicaemia 

327.  Atrophic  Striae 

Stripes,  at  first  red,  after- 
wards white,  and  resem- 
bling the  linese  gravi- 
darum. Not  necessarily 
over  the  seat  of  the  lesion. 

Appendicitis 

Enteric  Fever 

esp.  a  transverse  fine  above 
pateUaJ 

Pneumonia 

328.  White  Patches 
Albinism,  Partial 
Facial  Hemiatrophy 
Keloid 
Leprosy 
Leucodermia 

pigmented  border 
*Morphea 
not  hard 

Neuritis 

Raynaud's  Disease 
;  local  syncope ' 

324-328 


126 


SKIN 


White  Patches — continued 
*Scars 

Sclerodermia 
hard 
(See  Digiti  Mortui,  871) 

Cyanosis  (see  Face,  396) 

329.  Thickened   Skin 

Abscess,  Impending 

Arsenic  -poisoning 
soles  and  palms 

Cancer,  Acute  Mammary 
'  peau  d' orange  ' 
♦Cellulitis 

Erysipelas 

Ichthyosis 

Keratosis 
*Keloid 

Leprosy 

Lichen  ruber 

Paralysis  agitans,  n. 

Phlebitis 

Rhinoscleroma 

Scars 

Sclerema 

Sclerodactyla 
fingers  and  face 

Sclerodermia 

(Edema  (see  335) 

330.  Red  Skin 

*Abscess 
Cellulitis 
Chilblain 

Cirrhosis  of  Kidney 
or  reddish  brown 
♦Erysipelas 
♦Erythema 

,,         nodosum 
Erythromelalgia 


*Gout 

Lymphangiectasis 
Neuritis  (x) 
Osteitis,  Acute 
Pellagra,  I. 
Rubefacients 
Scalds  and  Burns 
♦Scarlatina 
Synovitis,  Acute 

(See  Erythema,  344  ;  Face 
387) 

331.  Sudamina  and  Miliaria 

Small  or  large  vesicles  due 
to  blocking  of  the  sweat 
glands. 

Cheiropompholyx 
♦Enteric  Fever 

Hyperidrosis 
♦Malignant  Fevers 

Meningitis,  Cerebro-spinal 
♦Phthisis 

Pneumonia,  Acute 

Relapsing  Fever 

Rheumatism,  Acute 

Trichinosis 

332.  Petechiae,  Ecchymosis,  or 
Hematoma 

The  effused  blood  in  a 
petechia  resembles  a  small 
circumscribed  bruise,  in 
ecchymosis  a  large  diffused 
one.  A  hsematoma  is  a 
blood  tumour  due  usually 
to  a  ruptured  vein. 

Ague 

Amyloid 

Anoemia 

Antitoxin,  Diphtheric 

♦Blows 

Some  persons,  esp.  females, 
bruise  from  very  slight 
injuries. 

328-332 


SKIN 


127 


Petechia,    Ecchymosis,    or 
Hematoma — continued 

Buhl's  Disease 
Cancer  of  Liver 
Cerebro -spinal  Meningitis 
Chloroma 
Cholera 

Cirrhosis  of  Liver 
Dilatation  of  Heart 
Diphtheria 
Dysentery- 
Drugs,  Occasional  Effects  of 
Antipyrin 
Arsenic 
Belladonna 
Butyl  Chloral 
Chloral 
Copaiba 
Ergot 
Iodides 
Iodoform 
Mercury 
Phosphorus 
Potassium  Chlorate 
Quinine 
Salicylic  Acid 
Sulphonal 
Veronal 
Endocarditis,  Ulcerative 
Enteric  (x) 
Erythema  multiforme 
Fleabites 
*Haemophilia 
Henoch's  Purpura 
Infantile  Scurvy 
Jaundice 
Kaposi's  Disease 

'  black-currant    rash  ' 

Leukaemia 
.  Locomotor  Ataxy 


Lymphosarcoma 
Malaria,  Severe 
Malignant  Fevers 

esp.  variola  and  typhus 

Measles 

Myelosarcoma 

Myelitis 

Myositis  Haemorrhagica 

Nephritis 

Neuritis,  Alcoholic 

Paroxysmal      Haemoglobin- 
uria 

Peliosis  Rheumatica 

Pernicious  Anaemia 

Phthiriasis 

Phthisis  (x) 

Plague 

Pseudo-Leukaemia       Infan- 
tum 

Psittacosis 

Ptomainism 
*Purpura  Haemorrhagica 

Pyaemia 

Remittent  Fever 

Rheumatism,  Acute  (x) 

*Rupture  of  Muscle 

if      of      T.      Achillis,      '  H 
shape ' 

*Rupture  of  Vein 

Scarlatina  (x) 
*,?  curvy 

Septicaemia 

Snake  Poison 

Splenic  Anaemia 

Tuberculosis,  General 

Typhic  State  (62) 

Valvular  Disease 

Variola  (x) 

Weil's  Disease 

Yellow  Atrophy,  Acute 
„      Fever 

332 


128 


SKIN 


333.  Trelat's  Naevi 

Small  multiple  noovi. 
These  in   the  subject   of  a 

breast    tumour    are    said 

to  point  to  : — 

Carcinoma 

334.  Rumpel-Lerde's  Test 

An  elastic  ligature  at  the 
forearm  produces  pete- 
chise  at  the  bend  of  the 
elbow. 

Diphtheria 

Measles 

Scarlatina 

rash  stage — in  half  a  minute 

Grocco's  test  for  slight  cases 
of  Purpura  and  Peliosis 
rheumatica  is  similar, 
the  result  being  slight 
punctiform  haemorrhages. 

335.  (Edema  and  Anasarca 

A  puffiness  of  the  skin  which 
on  long  pressure  with  the 
finger-point  leaves  a  pit 
lasting   about   a   minute. 
Anasarca    is    generalised 
oedema. 
*Abscess 
Amyloid,  in. 
Amyotonia  Congenita 
Ansemia 

Angioneurotic  (Edema 
Anthrax  (x)    g 
Aortic  Aneurysm 
„      Disease  (x) 
very  advanced  cases 
Atrophy  of  Heart 
*Beri-beri 
Bronchitis,  Chronic  (x) 
Buhl's  Disease 
♦Cellulitis 
Cirrhosis  of  Liver 
termination 


Cirrhosis  of  Lung 
Diabetes,  in. 
Dilatation  of  Heart 
Displaced  Heart 
Emphysema,  in. 
Empyema 
affected    side 

♦Erysipelas 
Erythromelalgia 
Essential  Dropsy  of  Children 
Extravasation  of  Urine 
Fatty       Degeneration       of 

Heart 
Fibroid  Disease  of  Heart 
Glanders 
*Gout 
Hypertrophy  of  Heart,  n. 
Hysterical  (Edema 

not  pitting 
Locomotor  Ataxy 

transient 
Malformation  of  Heart 
♦Mitral  Regurgitation 
Muscular  Atony,  Cong. 
Myositis 
Myxoedema 

not  pitting 
Nephritis,  Acute  and  Chronic 

Tubular 
Neuritis  (x) 
Pericradium,  Adherent 
Perinephric  Abscess 

lumbar  region 
Pleural  Effusion 

same  side  (x) 
Pneumo-peritoneeum 

epigastrium 
Polymyositis 
Polyneuritis 
Scurvy  (feet) 
Suppurative  Synovitis 

333-335 


SKIN 


120 


(Edema     and      Anasarca — 
continued 
Syphilitic  Disease  of  Heart 
Trichinosis 

Tricuspid  Regurgitation 
*Urticaria 
♦Varicose  Veins 
Xeroderma  pigmentosum 

Excess  of  salt  in  the  dietary 
will  produce  oedema. 

(See  Limbs,  863  ;  Face, 
403) 

336.  Circumscribed  (Edema 

Abscess,  Superficial 

Aneurysm  of  Asc.  Aorta 

if  intra-pericardial,  nipple ; 
if  extra-pericardial,  fourth 
right  cartilage 

Aneurysm     of     Transverse 
Aorta 

above  left  clavicle 
Angioneurotic  (Edema 
Appendicitis  (x) 
Caries  of  Sternum 
Empyema 
*Encysted  Pleurisy 
♦Furuncle  in  Meatus 
Hepatic  Abscess 
Hydatids  of  Lung 
Mastoid  Abscess 
Mediastinal      Tumour       or 

Abscess 
Necrosis 

Neurasthenia,  Traumatic 
scalp 

Neuritis 
Osteomyelitis 
♦Parotitis 
Pericarditis,  Purulent 
Perinephric  Abscess 


Poisoned  Wounds 
Rickets  (x) 
♦Stings 

Thrombosis  of  Sinus 
scalp 

Tubercle  of  Ribs 
Tumour  of  Chest  Wall 
(See  Limbs,  863) 

337.  Blue  (Edema 

Asthma,  Spasmodic 

Hysteria 

non- pitting  ;        ('  Charcot's 
(Edema  ') 

Mitral  Disease 
Syringomyelia 

(See  Cyanosis,  306) 

338.  Emphysema,  Interstitial 

Due  to   air   or   gas   in  the 

subcutaneous  tissue.    The 
skin  crackles  on  pressure. 

Broncho-pneumonia 
Caisson  Disease 
Foreign  Body  in  Lungs 
Fractured  Pelvis 

„  Ribs 

Glanders 
Perforation    of    (Esophagus, 

Stomach,  or  Bowel  (x) 
Phthisis 

Pneumothorax  (x) 
Rupture  of  Air  Cells 

from     shouting,     coughing, 
lifting,  etc. 

Ulceration  of  Larynx 
Wound    of    Lung,    Mouth, 
Larynx,  or  Intestine 

*#*  Some  cases  are  due  to 
infection  with  B.  aero- 
genes  capsulatus  and  a 
few  to  B.  coli. 

335-338 


130 


SKIN 


339.  Inelastic  Skin 

This  is  often  due  to  loss  of 
tone  in  the  minute  skin 
muscles,  as  is  seen  in  the 
skin  of  persons  who, 
formerly  stout,  have 
become  thin. 

*  Atrophy,  Senile 

Cholera 

Coma 

Diarrhoea,  Profuse 
*Enteric  Fever 

Meningitis 

Paralysis  Agitans 

Starvation 

Syphilis,  Hereditary 
*Typhic  State  (62) 

Typhus 

340.  Goose  Flesh 

A  roughened  skin  due  to 
spastic  contraction  of  the 
skin  muscles. 

Rigors  and  Chills  (236) 

341.  Glossy  Skin 

^Anasarca 
*Gout 
Injury  to  Nerves 
Leprosy — non-tuberculated 
Neuritis 
^Stretched  Skin 

from  any  cause 
Syringomyelia 
'  peau  lisse ' 

342.  Scaling  or  Desquamation 

Sequel  of  dermatitis  of  some 
kind. 

Antipyrin  Rash 

Belladonna  Rash 

Copaiba  Rash 

Dengue 

Dermatitis  exfoliativa  neo- 
natorum 


Desquamatio  Periodica 

Eczema 

Enteric  Fever  (x) 

Erysipelas 

Erythema  (x) 

Erythema  Scarlatiniforme 

appears  2nd  to  4th  day 
Favus 

yellow 

Gout 
Herpes 
Ichthyosis 
Lupus 
Measles 
branny 

Morphia  Rash 
*Pityriasis 
*Pityriasis  rubra 
flakes 

*Pityriasis  versicolor 
*Psoriasis 

Quinine  Rash 

Rotheln 
slight 

Scarlatina 

from  7th  day  to  about  7th 
week.  Flakes  are  less 
common  than  formerly 

Scurvy 

legs 
Seborrhcea 

fatty  scales 
Syphilis 

Tinea  tonsurans 
Xeroderma 

!**  Working  men  desquamate 
on  the  palms  when  out 
of  employment.  Carbolic 
acid  and  other  disinfec- 
tant lotions  or  baths  may 
produce  it. 

339-342 


SKIN 


131 


343.  Scars  follow  : — 

♦Abscess 

Acne  rosacea 

Anthrax 
*Boils 

Bubo 
*  Burns 

if  deep 
♦Carbuncles 

Chancre 

Ecthyma 

Gangrene 

Glands,  Tuberculous 

Gummata,  Suppurating 

Herpes  Zoster 
♦Lupus  erythematosus 

Lupus  exedens 
*Lupus  syphiliticus 
large 

Lupus  vulgaris 
bluish  and  papery 

Serpiginous  Syphilide 
bean-shaped 

Tubercles  (350) 
♦Ulcers 

Varicella  (x) 
♦Variola 

Wet-cupping 

♦Wounds 

Linear  scars  follow  over- 
stretching of  the  skin 
from,  oedema,  pregnancy, 
abdominal  tumours,  obe- 
sity, etc.  (linese  albicantes, 
see  822). 

344.  Erythema  (Diffused  Red- 
ness) 

Cerebro- spinal  Meningitis 
Dengue 

Dermatitis   exfoliativa  neo- 
natorum 


K 


Drugs,  Action  of : 
Antipyrin 
Antitoxin 
Arnica 
Arsenic 
Belladonna 
Boric  Acid 
Bromides 
Chloral 
Copaiba 
Croton  Oil 
Cubebs 
Iodides  (x) 
Xeo-salvarsan 
Quinine 
Rhubarb 
Salicylates 
Sulphonal 
Veronal 
♦Erysipelas 
Erythema  infectiosum 

circular    patches    beginning 
on  face 

Erythema  multiforme 
Erythema   scarlatiniforme 
common  after  operations — 
throat  normal  or  slightly 
reddened. 

♦Erythema  simplex 
Extravasation  of  L'rine 
'  Fourth  Disease  ' 
Gout 

Hydroa,  I. 
Influenza 

sometimes  scarlatiniform 

Intertrigo 

Kidney,  Cirrhosis  of 

Leprosy 

Malingering 

'  erythema  artefactum ' 
Myositis 
Pellagra,  I. 
2  343-344 


132 


SKIN 


Erythema — continued 
Phlebitis 
Polymyositis 
Primula  obconica 
contact  with 

Ptomainism 
Raynaud's  Disease 
Roseola,  Syphilitic 
Rotheln 
*Rubefacients 
♦Scarlatina 

neck  first — punctate 
Sleeping  Sickness 

annular 
Typhus (x) 

prodromal 
Urticaria 

around  wheals 

Variola  (x) 

prodromal  stage 

Also    from    irritant    baths 

or  lotions  and  from  soap 

enemata. 

345.  Macules  or  Flat  Coloured 
Spots 

Angiokeratoma 
Dermatitis  herpetiformis 
Erythrasma 
*Freckles 
Lupus 
Mycosis  fungoides 

patches 
Nsevus 

Peliosis  Rheumatica 
Purpura 
Roseola  (x) 
Spilus 
Syphilis 
Typhus 

mulberry — chiefly  on  abdo- 
men 


346.  Papules 

A  papule  is  a  solid,  circum- 
scribed, usually  transient 
elevation  less  than  a  split 
pea  in  size.  It  may  be 
the  first  stage  of  a  vesicle 
pustule,  or  crust. 

*Acne 
Anthrax,  I. 
Antitoxin  Injection 
'  Caterpillar  Rash  ' 
Copaiba  Rash 
Dermatitis  herpetiformis 
Eczema,  I. 
*Enteric  Fever 

lenticular — several  crops, 
chiefly  about  hypo- 
chondria 

Erythema  multiforme 
Influenza 
Lichen  planus 
flat-topped,  purplish 

Lichen  ruber 

flat  and  sometimes  umbili- 
cated 

Lichen  scrofulosorum 
confluent 

*Measles 

face  first ;  spots  isolated 
at  first,  afterwards 
grouped 

Miliaria  Papulosa 

Paratyphoid 

Phthiriasis 

Pityriasis  rubra 

Prurigo 

Psittacosis 

Roseola 

Rotheln 

Scabies 

Sporotrichosis 

344-346 


SKIN 


133 


Papules — continued 
Syphilis 

esp.        around       forehead 
('  Corona  Veneris  ') 

Varicella,  I. 
several  crops 

Variola 

first  3  days  of  eruption — 
face  and  wrists  first 

Verruca  plana 
Xerodermia 


347.  Vesicles       ('  Watery 
Heads ') 
Anthrax 

Antimony  externally 
Arnica  externally 
Arsenic-poisoning,  Chronic 
Bites 
Bromism 
Cheiropompholyx 
Dermatitis  herpetiformis 
„  repens 

*Eczema 
Erythema  multiforme 
Foot-and-Mouth  Disease 

hands  and  feet 
Glanders 
Grocer's  Itch 
Herpes  iris 
rings 

Herpes  simplex 

*Herpes  zoster 

track    of    a    nerve,    u     rt. 
intercostal 

Impetigo  contagiosa 
Lichen  urticatus 
Lymphangioma         circum- 
scriptum 


Miliaria 

Poliomyelitis,  Acute  (x) 
*Scabies 

esp.  between  fingers 

Sudamina 

Sulphur  Inunction 

Syphilis  (x) 

*  Varicella,  i. 

12th  to  36th  hour  of  disease, 
not  umbilicated,  collapse 
on  pricking,  several  crops, 
fluid  rarely  turbid.  Size 
variable,  more  numerous 
on  trunk  than  on  face 
and  limbs. 

Variola 

3rd  to  6th  day,  umbilicated, 
do  not  collapse  on  prick- 
ing, single  crop,  become 
turbid  before  drying  up. 
Size  uniform,  most 
marked  on  face  and  ex- 
tremities. More  on  back 
than  on  chest  and  abdo- 
men. 


348.  Bullae 

Anasarca 

Bromism 

Cheiropompholyx 

Dermatitis  herpetiformis 

Epidermolysis  bullosa 

Erysipelas 

Erythema  bullosum 

iris 
Gangrene,  i. 
Glanders 

Hydroa  gestationis 
Impetigo  contagiosa  (x) 
Iodism  (x) 
Leprosy 

Meningitis,  Cerebro-spinal 
Mor van's  Disease 

346-348 


134 


SKIN 


Bullae — continued 
*Pemphigus 
Raynaud's  Disease 

black  and  symmetrical 
Rupia,  I. 
Scurvy 

containing  blood 
Syphilis,  Hereditary 
Syringomyelia 

affected  limb 

Urticaria  bullosa 

Bullse  may  also  be  due  to 
burns,  friction  or  vesi- 
cants, or  to  Primula  obco- 
nica  or  Rhus  toxicoden- 
dron, and  they  occur  in 
workers  in  tar,  varnish, 
and  aniline  dyes. 

349.  Pustules  or  Mattery  Heads 

Anthrax 
*Ecthyma 
Eczema  pustulare 
Drug  Eruptions 

bromides,  iodides,  copaiba, 
etc. 

Glanders 
*Impetigo  contagiosa 
Porrigo 

Pyodermatitis  vegetans 
Scabies 
Sporotrichosis 
Sycosis 
Varicella  (x) 
Variola 


350.  Superficial      Nodules 
*  Tubercles ' 


or 


A  tubercle  is  a  large  papule 
which  does  not  undergo 
resolution  and  is  apt 
to  cicatrise. 


*Acne 
*Bromism 

Carcinoma,  Secondary 

Elephantiasis 

Epithelioma 

Gummata 

Iodism  (x) 

Keloid 

Lupus 
*Molluscum 

Neuro -Fibromata 

Neuroma 

Phyma 

Recklinghausen's  Disease 

generalised      neuro  -  fibro- 
mata 

Rodent  Ulcer,  i. 
Scrofula 
Sporotrichosis 
Sycosis 
Syphilis 
Vitiligo 
*Warts 
Yaws 

351.  Gangrene 
Aneurysm 
Arsenic-poisoning 
*Atheroma 
Cauda  Equina  Affections 
Claudication   Intermittente, 

in. 
*Diabetes 
Embolism 

s.  symmetrical 

Emphysema,  Cutaneous 
Endarteritis 
*Ergotism 
dry 

Ery  thromelalgi  a 
Iodides 

348-351 


SKIN 


135 


Gangkene — continued 

Impetigo  Contagiosa 

Leprosy 

surrounding  skin  pale 

Locomotor  Ataxy 

Leprosy 

Meningo-myelitis 

Lupus  vulgaris 

Morvan's  Disease 

ringed     with    '  apple    jelly 

Myelitis 

nodules ' 

Neuritis,  Peripheral 

Mycosis  Fungoides 

Orthoform,  Eifect  of 

with  tomato-like  growths 

Paralysis 
Phlebitis 

Pemphigus  vulgaris 

not  raw  underneath 

moist 

Psoriasis  Rupioides 

Pyaemia 

base  ulcerated 

Quinism 

*Raynaud's  Disease 

Ringworm  (x) 

♦Senility 

Rupia 

Syringomyelia 

laminated  cones 

Trauma 

♦Scabies 

Thrombosis 

Sycosis 

Tumours,  Pressure  of 

♦Variola 

Gangrene  may  be  caused  by 

Yaws,  Secondary 

tight  bandages   and   car- 

raspberry crusts 

bolic-acid  dressings. 

Crusts  often  hide  an  ulcer 

(364). 

352.  Crusts  or  Scabs 

Due  to  '  caked  '  discharge. 

353.  Wheals 

A  crust  may  be  the  last 

Like  nettle-stings 

stage  of  an  eruption  which 

Angeioneurotic  (Edema 

began  as  a  papule. 

Cerebro-spinal  Meningitis 

Acne  sebacea 

Dengue 

fatty 

Dermatitis  herpetiformis 

♦Ecthyma 

Gallstone  Colic  (x) 

♦Eczema 

Gastro-enteritis 

Eczema  rubrum 

Hydatids 

like  guttapercha  tissue 

Kidney,  Cirrhosis  of 

O                 J. 

Peliosis  Rheumatica 

Erythema  multiforme 

Polymyositis 

Favus 

Tapeworm 

yellow  '  scutula  '   or  cups — 

♦Urticaria 

scaly 

Also    Nettle-sting    and    the 

Herpes 

following  drugs  : 

Impetigo 

Antimony 

351-353 

136 


SKIN 


Wheals — continued 
Antipyrin 
Antitoxin 
Bromides 
Copaiba 
Iodides 
Morphine 
Quinine 
Santonin 
Sulphonal 

354.  Ulcers 

A    circumscribed    skinless 
area. 

Anthrax 
Atheroma 
Cancer 
Diabetes 
Eczema,  in. 
Elephantiasis  (x) 
Epithelioma 
Erythema  Induratum 
Frostbite 
ringers,  toes,  and  nose 

Gangrene 
Glanders 
Gout 
superficial,  over  gouty  joints 

Innervation,  Deficient 

see  Perforating   Ulcer  (866) 

Lupus  vulgaris 

with  '  apple  jelly  nodules  ' 

Rodent  Ulcer 

Sarcoma 

Scurvy 

*  bullock's  liver  crusts  ' 

Senile  Decay 


Syphilis,  Tertiary 

circular,  with  abrupt  edges 
and  dark  red  areola 

Trauma 
Tuberculosis 

on  neck  or  near  a  joint, 
oval  or  confluent,  bleed 
easily,  edges  undermined, 
pink    areola 

Varicose  Veins 

***  (Edematous  granulations 
usually  imply  diseased 
bone. 


355.  Condylomata 

Moist     flattened    swellings , 
occurring  near  junction  o  f 
skin   with   mucous  mem- 
brane. 

Syphilis 

356.  Skin  Organisms 

A  rapid  method  of  diag- 
nosing ringworm  consists 
in  dabbing  a  patch  with 
some  cotton  wool  soaked 
in  chloroform.  On  evap 
oration,  the  hairs  will 
look  as  if  dusted  with  hoar 
frost  (see  313). 

Acarus  Scabiei 

(Itch) 
Achorion  Schonleinii 

(Favus) 
Bacillus  Acnes 

(Acne,  Area,  Seborrhoea) 
Cimex  Lectularius 

Kala  Azar  (Host) 
Culex  Fatigans 

(Carrier  of  Filariasis) 
353-356 


SKIN 


137 


Skin  Organisms — continued 
Flask-shaped  Bacilli 
(Seborrhcea,  Area) 

Larvae  of  Flies 

(Myiasis) 
Microbacillus  of  Sabouraud 

(same  as  B.  Acnes) 
Microsporon  Audouini 

(Ringworm — 90    per    cent, 
of  London  cases) 

Microsporon  Furfur 
(Pityriasis  versicolor) 

Microsporon  Mentagraphytes 
(Sycosis) 

Microsporon    Minutissimum 
(Erythrasma) 


Morococcus  of  Unna 
(Eczema) 

Pediculus  Capitis 

Pediculus  Corporis 

(Phthiriasis  ;  said  also  to  be 
the  carrier  of  Typhus) 

Pediculus  Pubis 
Pulex  Penetrans 
Trichophyton  Megalosporon 

Ectothrix 

(Ringworm,  esp.  Kerion) 

Trichophyton  Megalosporon 
Endothrix 
(Ringworm) 

(For  Itching  see  218) 


356 


138 


THE  HEAD 


357.  THE  HEAD 

The  three  measurements  used  for  determining  the  size  of  the 
head  are,  (a)  from  one  meatus  to  the  other  ;  (b)  over  the  top  of 
the  head  from  the  root  of  the  nose  to  the  occipital  protuberance  ; 
and  (c)  horizontally  round  the  skull  on  the  level  of  the  supra- 
orbital ridges  and  the  occipital  protuberance. 


358.  Shape    and    Size  Altered 

Achondroplasia 

large  and  broad,  '  bull-dog  ' 
type  with  large  vault 

Acromegaly 

enlarged    bones    (esp.    inf. 
maxilla)  and  soft  parts 

Cretinism 

large,  flat-topped 
Hydrocephalus 

large  and  spherical 

Hypertrophy  of  Brain 

even  enlargement 
Idiocy,  Macrocephalic 

large  and  irregular 
Idiocy,  Microcephalic 

small  and  triangular,  with 
apex  at  crown 

Infantile  Hemiplegia 

flattened  on  one  side 

Leontiasis  Ossea 

large    and    globular,    with 
pronounced  orbits 

Mongolian  Imbecility 
short  and  spherical 

Myxcedema 

large,  with  '  full-moon  face  ' 

Osteitis  deformans 

uniformly  large  and  grow- 
ing, with  triangular  face 


Rickets 

quadrilateral  profile  ;  high, 
square,  and  prominent 
forehead 

Syphilis,  Hereditary 

depressed  sutures  sur- 
rounded by  bosses  termed 
Parrot's  Nodes  ('hour- 
glass '  or  '  hot-cross  bun  ' 
head). 

359.  Swellings  on  Head 

Abscess 

Cephalhaematoma        neona- 
torum 
Cirsoid  Aneurysm 

worm-like 

*Cysts,  Sebaceous 
Hsematoma 
Hernia  Cerebri 
Meningocele 
Mycosis  Fungoides  (x) 
Naevi 
Nodes 
Trauma 

Head  Fixed  (see  Stiff  Neck,  710) 

360.  Voluminous    or    Rolling 

Head 

Inability  to  support  the 
weight  of  the  head ; 
normal  under  2  months. 

357-360 


THE  HEAD 


139 


VOLUMINOUS        OR        ROLLING 

Head — continued 
Congenital  Myotonia  (x) 
Hydrocephalus 
Idiocy 

Multiple  Neuritis  (x) 
Myasthenia  Gravis 
*Rickets 

(See  Hypotonia,  1349) 


361.  Retracted 

Abscess,  Postpharyngeal 

„        Subtentorial 
*  Basilar  Meningitis 

tuberculous  or  simple 

Catalepsy 

Cerebro -spinal  Meningitis 
Cyanosis,  Acute 
Encephalitis,  Acute 
Faucial  Inflammation 
Haemorrhage,  Cerebellar 
Hydrophobia 
Hystero-epilepsy 
Meningitis,  Suppurative 
'  Meningisme  '  (Dupre) 
Otitis  Media,  Acute 
in  infants 

Paramyoclonus  multiplex 
Pneumonia,  '  Cerebral ' 
Post-basic  Meningitis 
Spinal  Meningitis,  Int. 
Strychnine-poisoning 
Teething  (x) 
Tetanus 

Thrombosis,    Sup.   Longitu- 
dinal 
Torticollis,  Spasmodic 
Tumours,  Subtentorial,  n. 
Typhic  State  (x)  (62) 
(See  Opisthotonos,  1426) 


362.  Oscillating 

Aortic  Aneurysm 
Epilepsy 

Friedreich's  Disease 
Hereditary  Cerebellar  Ataxy 
Meniere's  Disease 
Otitis  Media 
Paralysis  Agitans 
♦Rickets 

363.  Nodding   ('  Spasmus    Nu- 
tans *) 

Epilepsy 
Habit  Spasm 
Hysteria 

Miner's  Nystagmus 
(See  1413) 

364.  De  Musset's  Sign 

A  rhythmic  nodding  of  the 
head,  synchronous  with 
the  heart  beat. 

*  Aortic  Regurgitation 
Arterio-sclerosis 
Exophthalmic  Goitre  (x) 
Left  Hypertrophy 
with  arterio-sclerosis 

***  The  name  is  that  of  the  poet 
— a  sufferer. 

365.  Gould's  Sign 

The  patient  sees  best  with 
the  head  bowed. 

Retinitis  Pigmentosa 

366.  (Edematous 

*Abscess 
Anasarca 
Erysipelas 
Furuncle  in  Meatus 
behind  ear 

360-366 


140 


THE  HEAD 


(Edematous- 
Glanders 

forehead 


:ontinued 


Mastoid  Periostitis 
Mediastinal  Tumour 
Otitis  interna,  Suppurative 
behind  ear 

Thrombosis  of  Lat.  Sinus 
behind  ear 


Thrombosis      of      Superior 
Longitudinal  Sinus 
forehead 
(See  Anasarca,  335) 

367.  Enlarged  Veins 

Hydrocephalus 
Mediastinal  Tumour 
Thrombosis  of  a  Sinus 
Tuberculous  Meningitis 
Tumours  of  Neck 


368.  FONTANELLES 

The  small  soft  areas  on  a  baby's  head.  They  should  all  close 
before  the  end  of  the  second  year. 


369.  Bulging  Fontanelles 

Hydrocephalus 
Hypersemia  of  Brain 
Meningitis 
Tumour  of  Brain 
Ventricles,  Effusion  into 

370.  Depressed  Fontanelles 

Anaemia  of  Brain 

Cholera 

Diarrhoea 

Marasmus 

Spurious  Hydrocephalus 

Wasting  Diseases  (311) 

371.  Late  in  Closing 

Cretinism 
Hydrocephalus 
Mongolian  Imbecility 
Rickets 


372.  Large   Fontanelles 

Cretinism 
Hydrocephalus 
*Rickets 
Syphilis,  Hereditary 

373.  Broad  Sutures  or  Seams 

Cretinism 

Hydrocephalus 

Rickets 

374.  Overlapping  Sutures 

Infantile  Wasting  Diseases 
(see  Depressed  Fontanelles, 
370) 

375.  Craniotabes 

Areas  of  thinned  bone  in 
occipital  and  parietal 
regions. 

Hydrocephalus 

Rickets 

Syphilis,  Congenital 


366-375 


THE  HAIR 


J41 


376.  THE  HAIR 

377.  Weak  Hair. — The  breaking  strain  of  hair  may  be 
easily  estimated  by  using  a  Salter's  letter  balance.  Each  end 
of  the  hair  is  held  between  finger  and  thumb  and  its  middle  is 
stretched  over  the  letter  holder,  which  is  then  slowly  pulled  down 
by  the  hair  until  the  latter  breaks.  The  number  of  ounces 
at  which  it  breaks  is  noted.  The  author  made  a  large  number 
of  experiments  in  this  way,  and  found  that  6|  ounces  was  the 
general  average  for  hair,  that  white  hair  was  stronger  than  that 
which  had  not  changed  its  colour,  and  that  water  and  almost  all 
toilet  preparations  weakened  the  hair  to  some  extent,  while 
oils  strengthened  it.  The  curling  tongs  had  very  little  effect, 
but  stretching  produced  a  marked  weakening,  due  to  the  hair 
not  regaining  its  original  length. 

As  an  aid  to  diagnosis,  if  falling  hair  prove  of  normal  strength 
the  cause  must  be  in  the  scalp  or  in  the  failure  of  bodily  strength, 
e.g.  anaemia,  fevers,  etc. 


378.  Baldness  or  Thin  Hair 

Alopecia  universalis 
*An3emia 

Arsenic-poisoning 
*Convalescence  from  Fevers 

Cretinism 

Eczema,  Chronic 

Enteric  Fever 

Erysipelas 

Exophthalmic  Goitre 

Facial  Hemiatrophy 
on  wasted  side 

Gout 

Hydrocephalus 

Lymphadenoma  (x) 

Mongolian  Imbecility 
mousy 

Myxcedema 

Phthisis 

Progeria 

Psoriasis 
*Seborrhcea 


Senility 

Syphilis 

Thallium  Acetate,  Action  of 

It  is  sometimes  associated 
with  neuralgia  or  dental 
trouble,  and  is  often 
hereditary. 

379.  Bald   Patches 
*Alopecia  Areata 
Alopecia  of  Brocq 
depressed 

Eczema  (x) 
Facial  Hemiatrophy 
Favus 

Folliculitis  Decalvans 
Gummata 
Ichthyosis 
Impetigo 
sequel 

Lupus  erythematosus 
Keratosis 

376-379 


142 


THE  HAIR 


Bald  Patches — continued 
Morphea 
Psoriasis 
Rickets 
back  of  head 

*Ringworm 
*Scars 

Sclerodermia 

Seborrhoea 

Syphilis,  Secondary 

Variola 

(See  Scars,  343) 

380.  Hypertrichosis 
Idiocy 
Menopause 
Moles 
Nephroma 
Suprarenal  Tumour 

often  sudden 
Tuberculosis  of  Children 
down  or  lanugo 


381.  *  Point    of    Exclamation 
Hairs' (I) 

*Alopecia  Areata 
Ringworm,  in 
Seborrhoea  (x) 
Absent  in  Brocq's  Alopecia. 

382.  Matted  Hair 

This  is  generally  due  to  neg- 
lect of  combing  and  oiling 
during  a  severe  illness. 

Eczema 

*Pediculosis 

Plica  Polonica 

383.  Beaded  Hair 

Hodara's  Disease 
Leptothrix 
Piedra 

Trichorrhexis  Nodosa 
Trichosis,  Giovanini's 


379-383 


THE   FACE 


143 


384.  THE  FACE 

Pallor  is  chiefly  of  importance  when  the  patient  is  known  to 
have  had  a  good  colour  previously.  It  is  normal  in  night-workers 
and  those  who  have  insufficient  sunlight. 


385.  Pallid  (including  Anaemia) 

Anaemia  is  distinguished  by 
the  pallor  of  the  con- 
junctiva under  the  lids. 

Amenorrhcea 

Amyloid 
*Anaemia 

Ankylostomiasis 
*Aortic  Regurgitation 
„      Stenosis 

Aplastic  Anaemia 

Arsenic-poisoning 

Arterio-sclerosis 

or  cyanosed 

Atony  of  Stomach 

Atrophy  of  Heart 

Banti's  Disease 

Bilharzia 

Cancer  of  Pancreas 

Chloroma 

Chlorosis 

in  blondes 
Cholera 

Dilatation  of  Heart 
Dysentery 
Endocarditis 
Exophthalmic  Goitre 
Haematocele 
♦Haemorrhage 
Hyperlactation 
Inversion  of  Uterus 
Leukaemia 
Lymphadenoma 
Malaria 
Menorrhagia 


Mercurialism 
Mitral  Stenosis,  I. 
patchy 

Multiple  Myomata 
Myocarditis,  Acute 
Myxcedema 

waxy 
Nephritis,  Chronic 
Ovarian  Disease 
Periarteritis  Nodosa 
Pernicious  Anaemia 
Phthisis,  I. 
Plague 

Relapsing  Fever 
Rheumatoid  Arthritis 
Status  Lymphaticus 
Tabes  mesenterica 
Thrombosis    of    Pulmonary 

Artery 
Trichinosis 
Tuberculosis 
Uterine  Fibroid 

386.  Transient  Pallor 

Alcoholic  Coma 
Angina  Pectoris 
Asthma,  Spasmodic 
or  cyanosed 

Colic 
*Collapse 

Compression  of  Brain,  in. 
♦Concussion  of  Brain 

Epilepsy,  I. 

Faints 

Gastric  Irritation 

Meniere's  Disease 

384-386 


144 


THE  FACE 


Transient       Pallor  —  con- 
tinued 
Petit  Mai 
*Shock 

'  Spinal  Concussion ' 
*Syncope 
Trance 
Tuberculous  Meningitis 

***  Also   poisoning   by   depres- 
sants. 

387.  Flushed  Face 

Ague 

hot  stage 
Alcoholism,  I. 
Apoplexy 
Cancrum  Oris 

one  cheek 

Concussion  of  Brain,  in. 
Enteric  Fever,  in. 
hectic 

Fevers,  i. 

Hysterical  Convulsions 

Paralysis  of  Sympathetic 

unilateral 
Phthisis,  in. 

hectic 

Pleurisy,  Acute 
Pneumonia,  Acute 
esp.  on  affected  side 

Remittent  Fever 
Rheumatism,  Acute 
Uterine  Tumours 

A  flushed  face  is  not  incon- 
sistent with  anaemia. 

388.  Transient  Flushes 

Amenorrhea  a 
Chlorosis 
Constipation 
Dysmenorrhea 


Enteric  Fever 

Epileptic  Aura 

Exophthalmic  Goitre 

Indigestion 

Lactation 
*Menopause 

Neuralgia,  Trigeminal 

Neurasthenia 

Nitrite  of  Amyl 

Nitroglycerin 

Pregnancy 
*Tuberculous  Meningitis 

389.  Grey  or  Slaty 

Antifebrin 

Argyria 

Hse  machrom  atosis 

Pellagra 

Sulph-hsemoglobinuria 

390.  Earthy  or  Sallow 
Anaemia  of  Dark  Persons 
Atony  of  Stomach 
Bromism 

Cancerous  Cachexia 
Chlorosis 

greenish  grey  in   dark  per- 
sons 

Cirrhosis  of  Liver 

Colitis 

*Constipation 

Duodenal  Catarrh 

Enteritis,  Chronic 

Exophthalmic  Goitre 

Facial  Hemiatrophy 

parchment-like        yellowish 
patches 

*Faecal  Accumulation 

Fatty  Degeneration  of  Heart 

Gastritis,  Chronic 

Hepatic  Abscess 

Lead-poisoning 

386-390 


THE   FACE 


145 


Earthy  or  Sallow — continued 
Mediastinitis 
Pleurisy  in  Children 
Rheumatoid  Arthritis 
*Syphilis,  Hereditary 
'  cafe  au  lait ' 

391.  Lemon  Yellow 

Aplastic  Anaemia 
Congenital  Cholaemia 
*Pernicious  Anaemia 


392.   JAUNDICE 
ICTERUS 


0  R 


In  old- standing  cases,  and 
especially  in  cancer  of  the 
liver,  the  skin  becomes 
greenish,  owing  to  the 
conversion  of  bilirubin 
into  bilverdin. 


393.  Nervous   Jaundice 

Anxiety 

Concussion  of  Brain  (x) 
Fourth  Ventricle,  Lesion  of 
Fright,  etc. 
Menstruation  (x) 

394.  Obstructive  Jaundice 

(a)  Intrinsic 
Obstruction  within  the  duct. 

Cancer  of  Duct 
*Catarrh  of  Bile-ducts 
,,        of  Duodenum 

Cholangitis 

Chronic  Fibrous  Cholangitis 

Congenital     Deficiency      of 
Duct 

Distomata 

Foreign  Bodies  from  Intes- 
tines 


Gallstones 

absent  or  late  when  in 
cystic  duct 

Hydatids 

rupturing  into  duct 
Icterus  neonatorum 
'Inspissated  Bile'  (?) 
Roundworm 

in  bile-duct 
Stricture  of  Duct 

spasmodic  or  organic 
Tumefaction  of  Duct-wall 

(6)  Extrinsic 

Pressure  upon  the  duct  or 
its  branches. 

Abscess,  Hepatic  Dysenteric, 

or  Pyaeinic 

Adhesions,  Peritonaeal 

Aneurysm 

abdominal  aorta,  coeliac 
axis,  hepatic  artery,  or 
superior  mesenteric  artery 

Cancer  of  Liver,  Bile  Duct, 
Duodenum,  Pancreas, 
Right  Kidney,  or  Omen- 
tum 

Cirrhosis  of  Liver 
slight 

Cyanotic  Liver 
from  mitral  disease,  etc. 

Cystic  Tumour  of  Duct 
Duodenal    Scar    from    old 

Ulcer 
Duodenitis 

Faecal  Accumulation  (x) 
Glands,   Enlarged  Portal 

from  cancer,  leukaemia, 
lymphadenoma,  lympho- 
sarcoma, tuberculosis  or 
syphilis 

390-394 


146 


THE  FACE 


Obstructive  Jaundice — con- 
tinued 
Hepatitis,  Acute  (x) 
Hydatids 

Icterus  neonatorum 
Kink  of  Bile  Duct 

from      tumours,      Riedel's 
lobe,  etc. 
Movable  Kidney  (rt.) 

intermittent 
Pancreatitis 
Perihepatitis 

from  contraction 
Peritonitis  (x) 

from  contraction 
Pneumonia,  Acute 

slight 
Pregnancy  (x) 
Pylephlebitis,  Suppurative 
Splenomegaly,  Gross 
Syphilitic  Liver 
Tumour  of  Duodenum,  Rt. 
Kidney,    Rt.    Suprarenal 
Capsule,  Liver,  Pancreas, 
Ovary,     Omentum,    Sto- 
mach,   Colon,    or    Uterus 

395.  Toxemic  Jaundice 

Acute  Yellow  Atrophy 
Buhl's  Disease 
Congenital  Cholaemia 
Endemic  Jaundice 
Endocarditis,  Ulcerative  (x) 
Hsemoglobinuria  Infantum 
Haemorrhage 
Influenza  (x) 
Malaria,  in. 
Pernicious  Anaemia 

Intermittent 
Poisoning       by    Antimony, 
Arseniuretted   Hydrogen, 


Chlorate  of  Potash,  Cop- 
per, Liquid  Chloroform, 
Mercury,  Phosphorus,  or 
Snake-venom 

Pyaemia 

Relapsing  Fever 

Remittent  Fever 

Typhus 

Weil's  Disease 
temporary 

Yellow  Fever 

396.  Lividity  or  Cyanosis 

Usually  due  to  insufficient 
air  reaching  the  blood 
or  vice  versa. 

Ague 

cold  stage 

Alcoholism 

Aneurysm,  Intrathoracic  (x) 

„  of  Heart 

Arterio-sclerosis,  in. 
Ascites,  Extreme 
Asphyxia 

*  Asthma,  Spasmodic 
Bronchial  Glands,  Enid. 

*  Bronchitis,  Acute 

,,  Plastic 

Broncho-pneumonia 
Bulbar  Paralysis 
Cancrum  Oris 

one  cheek 
Cholera,  HI. 
Collapse  of  Lung 
Cyanosis,  Enterogenous 
Dilatation  of  Heart 
Diphtheria,  Laryngeal 
Displaced  Heart 
Dyspnoea,  Acute 
Emphysema,  in. 
Epilepsy,  ii. 

394-396 


THE  FACE 


147 


Lividity — continued 
Fibroid  Phthisis 
*Foreign    Body    in    Air-pas- 
sages 
Glossitis,  Acute 
Hemoglobinuria,  Infantile 
Hernia,  Diaphragmatic 
Hooping- Cough 
end  of  paroxysm 

Hydrothorax,  Sudden 

Hypertrophy  of  Right  Ven- 
tricle 

Hypostatic     Congestion     of 
Lungs 

Iodism  (x) 

oedema  laryngis 

Intercostal  Rheumatism 
Laryngitis,  Acute 
Laryngismus  Stridulus 
Locomotor  Ataxy 

laryngeal  crisis 

Lung,  Embolism  of 
,,      Sarcoma  of 
*Malformation  of  Heart 

esp.     pulm.    stenosis ;     less 
marked  in  patent  septum 

Mediastinal  Tumours 
Mediastinitis 
*Mitral  Disease 
Myocarditis,  Acute 
(Edema  of  Lung 
Laryngis 
Paralysis,   Bilateral  Abduc- 
tor 
„  of  Diaphragm 

„  of   Respiratory 

Muscles 
Pericardial  Effusion 
Pericarditis 
Pericardium,  Adherent 


Pernicious  Intermittent 

Peritonitis,  Acute  (x) 

Pleurisy 

,,         Diaphragmatic 

Pneumonia,  Acute 

Pneumothorax 

Poisoning  by  Anilines,  Anti- 
febrin,  Antipyrin,  Hydro- 
cyanic Acid,  Nitro-Ben- 
zine,  Opium,  Phenacetin, 
Strychnine  and  Intestinal 
Toxines 

Pulmonary  Apoplexy 

Retropharyngeal  Abscess 

Spasm,  Adductor 

Splenomegalic  Polycythe- 
mia 

Sunstroke 

Tetanus 

Thrombosis  of  Pulmonary 
Artery 

Trypanosomiasis 
in  patches 
*Tuberculosis,  Acute 

greater  than  in  bronchitis 

Tumour,  Laryngeal 
Tympanites 
Vena  Cava,  Obstructed 
(See  Dyspnoea,  1223) 


397.  Venous  Stigmata 

Patchy  redness  showing  groups 
of  enlarged  venules. 

*Alcoholism 
Cirrhosis  of  Liver 
Erythromelalgia 
Facial  Hemihypertrophy 
Paroxysmal  Cough 


Vomiting,  Chronic 


l2 


396-397 


148 


THE  FACE 


398.  Ulceration,  Facial 

Lupus  vulgaris 

'  apple  jelly  nodules  ' 

Rodent  Ulcer 
rolled  up  edges 

Syphilis,  Secondary  or  Ter- 
tiary 
(See  Ulcers,  354) 

399.  Sides  Unequal 

Congenital  Asymmetry 

„  Torticollis 

Facial  Hemiatrophy 

both    tissues    and    muscles 
wasted 
Facial  Hemihypertrophy 
Facial  Paralysis,  Old 

esp.    if   dating   from   child- 
hood 
Infantile  Paralysis,  Old 
Paralysis  of  Cervical  Sym- 
pathetic 

400.  Flapping  Cheek 

*Apoplexy 
Coma  (64) 

Diphtheritic  Paralysis 
♦Facial  Paralysis 

toothlessness 
may  be  misleading. 


***  Unilateral 


401.  Pinched   Face 

Ague  (cold  stage) 
Atrophy 
Cholera 
Colic 
*Collapse  (235) 
Death,  Impending 
'  Facies  Hippocratica ' 

Diarrhoea 


Dysentery 
♦Enteric  Fever 
Exophthalmic  Goitre 
Gangrene  of  Lung 
Haemorrhage 

Idiopathic    Muscular    Atro- 
phy 
Lipodystrophia,  Progressive 

Perforation  of  Stomach   or 

Bowel 
*Phthisis 

Remittent  Fever 

Rheumatoid  Arthritis 

Sclerodermia 

Spinal  Caries 

Strangulated  Hernia 

Tabes  mesenterica 
♦Tuberculosis 
♦Wasting  Diseases  (311) 

402.  Thickened  Features 

Nonpitting 

Acromegaly 

Cretinism 

Leprosy 

Myxcedema 

Sclerema 

403.  Swollen  Face 

Local  or  general 

♦Abscess 
Actinomycosis 
lower  jaw 

Anasarca  (335) 
Aneurysm,  Thoracic 
Angioneurotic  (Edema 
Anthrax 
Boils 

Cancrum  Oris 
one  cheek 

398-403 


THE    FACE 


140 


Swollen  Face — continued 
Chloroma 
temples 
Dacryocystitis 
Dropsy  etc.,  of  Antrum 
Dengue 

*Dental  Abscess 
Dyspituitarism 

'  pudding  face ' 
Emphysema,  in. 
Enlarged  Bronchial  Glands 

(x) 
*  Erysipelas 
Exophthalmic  Goitre 
Hooping  Cough 
Hydrocephalus  (x) 
Leprosy 

Mediastinal  Tumour 
*Mitral  Regurgitation 
Mumps 
Myxoedema 
*Nephritis,  Tubular 
(Edema  (335) 

„  Circumscribed 

Acute 
Parotid  Tumour,  Gaseous 
Parotitis,  Gouty 
Pneumothorax 
Scurvy 
Thrombosis    of    Cavernous 

Sinus 
Thrombosis  of  Superior  Lon- 
gitudinal Sinus 
forehead 
Trichinosis 
Trypanosomiasis 
*Urticaria 
Variola  ^Confluent 

A  puffy  face  is  also  common 
in  wasted  infants,  and  it 
may  be  caused  by  cough- 
ing or  vomiting. 


404.  Prae-auricular  Gland  En- 
larged 

The  area  of  irritation  in- 
cludes cheek,  eyelid,  ear, 
and  temple. 

Chancre  of  Eyelid 

Conjunctivitis,  Parinaud's 

Dental  Caries,  Upper 

Epithelioma 

Melanotic  Sarcoma 

Septic  Infection 

Tuberculosis  of  Ear 

Varicella 

405.  Twitchings  of  Face 
Blepharospasm 

*Chorea 
Convulsions 
Dentition 

esp.  wisdom  teeth 
Epilepsy 
Exophthalmic  Goitre 

of  levatores  palpebrarum 
'  Abaclie's   Sign  ' 

General  Paralysis 

lips 
Gilles      de      la      Tourette's 
Disease 
*Habit  Spasm 
Hysteria 
Meningitis 
Mimic  Tic 
*Muscular  Asthenopia 
Paramyotonia  congenita 
lower  part — excited  by  cold 

Polypus 
Strychnine 
Tetanus 
Tic-douloureux 
Tooth,  Carious 

(See  Clonic  Spasms,  1406) 

403-405 


150 


THE  FACE 


406.  Frontalis  Symptom 

Involuntary  persistence  of 
a  voluntarily  induced 
wrinkling  of  the  forehead 

Paralysis  Agitans 

407.  Facies 

An  experienced  clinician 
may  sometimes  make  a 
diagnosis  at  a  glance. 

Abdominal  Disease 

pinched  face,  sunken  eyes, 
anxious  expression 

Acromegaly 

lower    jaw    and    all    bony 
facial     prominences     en- 
larged.   Long  thick  upper 
lip 
Adenoids 

vacant  expression,  open 
mouth  and  collapsed  nos- 
trils 

Chloroma 

frog -like 

Chronic  Bright' s  Disease 

puffy,  putty  colour,  ex- 
pressionless 

Cretinism 

face  broad ;  ears  large ; 
nose  flat  and  large ;  lips 
and  eyelids  thick ;  mouth 
open 

Enteric  Fever 

drawn  inelastic  skin,  pallor, 
resigned  expression 

Exophthalmic  Goitre 

eyes  prominent  and  staring  ; 
face  drawn  and  thin ; 
tremors 

Facies  Leonina  (Leprosy) 
Due    to    thickened    ridges 
of  skin 


Hydrocephalus 

prominent  forehead  and 
small  features — '  Marshall 
Hall  Facies  ' 

Leontiasis  Ossea 

bony  prominence  over  orbit. 
Lion-like  expression 

Locomotor  Ataxy 

forehead  wrinkled ;  eye- 
lids di'ooping  ;  pupils  con- 
tracted and  fixed 

Miculicz'  Disease 

marked  broadening  of  the 
cheeks  with  external 
ptosis 

Mitral  Disease,   Uncompen- 
sated 

puffy  face,  purple  com- 
plexion, anxietas 

Mongolian  Idiocy 

ears  large ;  palpebral  fis- 
sures sloped  downwards 
and  inwards ;  tongue 
thick  and  protruded ; 
complexion  florid 

Myasthenia  Gravis 

eyes  drooping ;  lower  jaw 
dropped.  Sometimes  a 
'  nasal  smile ' 

Myxcedema 

swollen  expressionless  fea- 
tures, thick  lips  and  ears, 
scanty  hair 

Paralysis  Agitans 

face  stiff — as  if  starched, 
eyelids  retracted,  eyeballs 
restless 

Syphilis,  Congenital 

bumpy  overhanging  fore- 
head, pug  nose,  cafe-au- 
lait  skin,  radiating  lines 
at  angles  of  mouth 

406-407 


THE  FACE 


151 


Facies — continued 

Typhic  or  Typhoid  state 

flushed  cheeks,  bright  eyes, 
tremulous  lips 

***  Facies  Hippocratica  occurs 
in  the  dying  and  is  marked 
by  pinched  and  curved 
nose,  sunken  eyes  and 
temples,  open  mouth,  etc. 


408.  Jadelot's  Traits 

Labial  Line 

A  line  extending  outwards 
from  angle  of  mouth. 
Respiratory  Diseases 


*  * 
* 


Nasal  Line 

A  line  starting  from  the 
nose  and  forming  a  semi- 
circle round  the  mouth. 

Digestive  Diseases 

Dr.  Ainslie  Hollis  has 
called  attention  to  varia- 
tions in  the  angle  of  the 
naso-labial  fold. 


409.  Omega  Melancholicum 

Vertical  folds  resemble  the 
Greek  letter  a>  between 
the  eyebrows  (Schuelc's 
Sign) 

Melancholia 


407-409 


152 


THE  EXPRESSION 


410.  THE  EXPRESSION 

In  organic  aphasia  the  expression  sometimes  represents  the 
opposite,  or  a  different,  emotion  ;  so  that  a  distressed  look  may 
be  indicative  of  pleasure.  The  observation  has  doubtless  been 
made  by  others  ;  but,  if  so,  I  have  found  no  record  of  it.  Since 
this  was  written,  it  has  been  termed  'paramimia.'     (See  1249.) 


411.  Vacant  Expression 

Adenoids 

Anaemia,  Advanced 

Bulbar  Paralysis 

Collapse 

Cretinism 

Dementia 

Diphtheritic  Paralysis 

Disseminated  Sclerosis 

Enteric  Fever 
*Facial  Paralysis 

Hydrocephalus 

Hysteria 

Idiocy 

Idiopathic    Muscular    Atro- 
phy 

Landouzy-Dejerine's    Para- 
lysis 

Myasthenia  Gravis 

Myxcedema 
sad 

Neuritis 

Optic  Thalamus,  Lesion  of 
*Paralysis  Agitans 
'  Parkinson's  mask ' 

Paralysis,  General 
Plague 
Tetanus,  I. 
Typhus  A 
Worms 


412.  Leonine  Expression 

Leontiasis  Ossea 
bony  masses 

Leprosy 

Masses  of  thickened  skin 

413.  Anxious  Expression 
('  Anxietas ') 

Aneurysm 
*Angina  Pectoris 

Appendicitis 

Colic  (122) 

Diaphragmatic  Pleurisy 

Dysentery 
*Dyspnoea,  Acute  (1223) 

Emphysema,  Interstitial 

Empyema 

Fatty  Degeneration  of  Heart 

Fractured  Ribs  or  Sternum 
*Gallstone  Colic 

Gangrene  of  Lung 

Glossitis,  Acute 

Hepatic  Abscess 

Hydrophobia 

Injuries,  Severe 
*Intestinal        Obstruction, 
Acute 

Laryngitis,  Acute 

,,  Diphtheritic 

Lead  Colic 

Myocarditis,  Acute 

410-413 


THE  EXPRESSION 


153 


Anxious — continued 
*(Edema  Laryngis 

Pericarditis 

with  lips  retracted 

Perihepatitis 

Peritonitis,  Acute 

Pleurisy,  Acute 

Pneumonia,  Acute 

Pneumothorax 

Septicaemia 
♦Spasmodic  Asthma 
♦Strangulated  Hernia 

Uraemia 

414.  Threatening  Expression 

Delirium  Tremens 

or  suspicious 
Encephalitis 
Hydrophobia 
*Mania 

415.  Unmeaning  Grimaces 

♦Chorea 

♦Gilles    de    la    Tourette's 

Disease 
Hereditary         Cerebellar 

Ataxy 


Hydrocephalus 

]  lysteria 

Insanity 

Malingering 

Spasm  of  Facial  Nerve 

Strychninism 

Tetanus 

Tic  Convulsif 

(See  Twitchings,  1407) 

416.  Risus  Sardonicus 

A  drawing  outwards  of  the 
angles  of  the  mouth. 

Abdominal  Cancer 

Catalepsy 

Hysteria 

Inflammation  of  Diaphragm 

Landouzy-Dejerine        Para- 
lysis 
'  transverse  smile ' 

♦Peritonitis 
Scars,  Contraction  of 
Sclerodermia,  Facial 
Spasm  of  Facial  Nerves 
Strychnine  -  poisoning 

♦Tetanus 
Ulceration  of  Intestine 


413-416 


154 


THE  EARS 


417.  THE  EARS 

To  examine  the  tympanic  membrane,  a  Gruber's  speculum, 
a  strong  light,  and  a  laryngeal  mirror  of,  preferably,  4-in.  focus, 
should  be  used,  or,  failing  this,  Brunton's  Auriscope.  The  external 
car  being  drawn  upwards  and  backwards  (in  a  child  simply 
backwards),  the  speculum  is  gently  inserted  for  about  half  an 
inch  or  so  as  to  stop  short  at  the  bony  portion  of  the  canal.  The 
light  should  be  thrown  slightly  upwards.  Wax  must  be  softened 
by  hydrogen  peroxide  and  removed  by  syringing  ;  hairs  should 
be  either  smeared  flat  with  lanoline  or  removed  with  the  scissors. 


418.  Malformations 

Absent  Auricles 

or  represented  by  tubercles 

Accessory  Auricles 

Atresia  Meatus 

Fistulous  Auricles 

Frostbite 

Also    injuries    such    as    are 
received  by  prize-fighters. 

419.  Tophi 

nodules  on  ears 
Gout  in  system 

420.  Hsematoma        (Blood 

tumour) 

It   is   much   commoner   on 
the  left  ear. 

*Dementia 
Epilepsy 

General  Paralysis 
Idiocy 

especially  in  males 
Mania 
Melancholia 
Trauma 


421.  Waxy  Ears 
Addison's  Disease 

*Anaemia 
Chlorosis 
Frostbite,  n. 
Leukaemia 
Myxcedema 

(See  Pallor,  385) 

422.  Livid  Ear 
Cold 

Cyanosis  (396) 
Dyspnoea  (1223) 
Malformation  of  Heart 
Nsevus 

423.  Swollen  Ear 

Abscess 

Blows 

Erysipelas 

Furunculosis 

Gummata 

Herpes 

Inflamed  Tophi 

Mastoiditis 

the  auricle  projecting  down 
wards  and  outwards 

417-423 


THE  EARS 


155 


Swollen"  Eae — continued 
Naevus 
*<Edema  (x)   (335) 
Perichondritis,  Acute 
Stings 

424.  Gangrenous 
Frostbite,  in. 
Raynaud's  Disease 
Trauma 

425.  Growths  on  Ear 
Aneurysm,  Cirsoid 

*Angeioma 

Chondroma 

Dermoid  Cysts 

Epithelioma 

Rodent  Ulcer 

Sarcoma 
*Sebaceous  Cyst 

426.  Bleeding  from  Meatus 

u  due  to  ruptured  mem- 
brane. 

Caisson  Disease 

Erosion 

into  lateral  sinus  or  internal 
carotid  artery 

Fracture  of  Base  of    Skull 

or  of  Glenoid  Fossa 
Otitis,  Acute  Hemorrhagic 
Polypus 
*Trauma 

including  a  blow  on  the 
chin 

Caution. — The  blood  may 
have  trickled  into  the  ear 
from  a  neighbouring  cut. 

427.  Swelling  in  Meatus 

Diphtheria 
Exostosis 


*Furuncle 

Granulations 

Hyperostosis 

Mastoiditis 

Otomycosis 

Parotid  Abscess 

Perichondritis 
*Polypus 

428.  Otorrhoea  (Discharge  from 
Meatus) 
Abscess    Bursting  into  Ear 

cerebral  (x),  mastoid,  teni- 
poro -maxillary  or  paro- 
tidean 

Carcinoma 

Caries  or  Necrosis  of  Tem- 
poral Bone 
offensive 

Diphtheria  of  Meatus 
Eczema  of  Meatus 
Epithelioma 
Foreign  Body  in  Meatus 
Fracture  of  Base  of  Skull 
cerebro-spinal  fluid 

*Furuncle  in  Meatus 
Granulations 
Labyrinth,    Injury    to 

Liq.  Cotunnii 
*  Otitis  media,  Suppurative 
fetid ;   often  blood-stained 
Otitis  media,  Tuberculous 
thin  and  offensive 

Pachymeningitis 
Polypus 

blood-stained 

Sebaceous    Cyst,   Suppurat- 
ing 
Thrombosis  of  Lateral  Sinus 
423-428 


156 


THE  EARS 


Otorrhcea — continued 

Asequelaof  Measles,  Mumps, 
Scarlatina,  Teething,Diph- 
theria  or  Tonsillitis — per 
Eustachian  Tube 

***  Liquid    cerumen    is    some- 
times  mistaken   for   pus. 
Cerebro-spinal  fluid  does  not 
stiffen  linen. 


429.  Membrane   Perforated   or 
Ruptured 

A  pulsating  cone  of  light 
precedes  perforation  and 
a  pulsating  drop  of  pus 
follows  it. 

Middle  Ear  Suppuration 
Myringitis 


Trauma 

sneezing,     over-inflation, 
syringing,  diving,  etc. 

Tuberculosis 

multiple  at  first 

430.  Otoscope 

The  sound  heard  during 
Eustachian  inflation 
should  be  normally  of  a 
soft  blowing  character. 

Eustachian  Obstruction 

distant 
Otosclerosis 

very  loud 

Retracted  Drum 

distant ;  followed  by  a 
click 

Tympanum,  Perforated 
loud  hissing  and  squeaking 


428-430 


THE   HEARING 


157 


431.  THE  HEARING 


The  hearing  centre  is  in  the  middle  of  the  first  temporal 
convolution. 

In  testing  the  hearing,  a  uniform  whisper  should  be  employed. 
This  is  audible,  normally,  25  ft.  away.  Patients  with  nerve 
deafness  hear  low-pitched  sounds  the  best  ;  those  with  ob- 
structive or  middle  ear  deafness,  high-pitched  sounds.  The 
patient  should  be  so  placed  that  he  cannot  see  the  surgeon's 
lip  movements.     The  ears  should  be  plugged  alternately. 

432.  Watch  Tests. — The  same  watch  must  be  used.  It 
should  be  held  far  away  at  first  and  then  gradually  approached 
until  the  patient  by  raising  his  finger  indicates  that  it  has  become 
audible.  It  may  sometimes  take  the  place  of  a  tuning-fork 
in  Weber's  Test.  The  patient's  eyes  must  be  closed,  especially 
in  cases  where  simulation  is  suspected. 


433.  Deafness 

Adenoids 

Ankylosed  Ossicles 

Atrophy  of  Brain 

Auditory  Neuritis 

Boil  in  Meatus 

Chloroma 

Congenital  Defect 
*Coryza 

Diphtheria 

Emotions 

Enteric  Fever 
*Eustachian  Obstruction 
drum  retracted 

Exanthemata 

slight 
Facial  Paralysis 

in  children 

Haemorrhage,  Intracranial 
Hay  Fever 
Hydrocephalus 
Hysteria 


Labyrinth,  Tumour  or  Can- 
cer of 

Lead-poisoning  (x) 

Lesion  of  Medulla,  Pons, 
Superior  Temporo-sphen- 
oidal  Convolution,  Cere- 
bellum or  Corpora  Quad- 
rigeniina 

Leukaemia,  in. 

Locomotor  Ataxy  (x) 

Measles 

Meniere's  Disease,  n. 

Meningitis 
esp.    basilar 

Meningitis,  Cerebro-spinal 

Mental  Strain 

Mumps 

Myxcedema 

Nephritis,  Chronic 
*Nervousness 

Otitis  interna 
*     .,      media 

Pernicious  Anaemia 

431-433 


158 


THE    HEARING 


Deafness — continued 
Pharyngitis 
Polypi,  Aural 
„        Nasal 
Rheumatoid  Arthritis 
Ruptured  Tympanum 
Shock 
Syphilis 
Typhus 
Uraemia 
*Wax  in  Meatus 

Deafness  also  occurs 
amongst  boiler  -  makers, 
divers  and  caisson  workers, 
and  in  persons  taking 
salicylates,  quinine,  bro- 
mides and,  though  more 
rarely,  mercury. 

434.  Exalted  Hearing  or  Hy- 
peracusis 

Convalescence  from  Fevers 

Epilepsy 

Gastritis,  Acute 

Hydrophobia 

Hypochondriasis 
*Hysteria 

Inflammation    of    Brain    or 
Membranes 

Migraine 

Nervousness 
*Neurasthenia 

Nucleo-Facial  Paralysis 
stapedius  muscle 

Tetanus 
Tumours  of  Brain 

435.  Dysacusis 

An  ordinary  sound  produces 
an  unpleasant  sensation. 

Hysteria 

Nervous  Irritability 

Neurasthenia 


436.  Paracusis  Willisii 

The    hearing    is    better    in 
noisy  surroundings. 

Middle  Ear  Catarrh 
Otosclerosis 

437.  Autophonia 

Increased  resonance  of  one's 
own  voice  in  the  head. 

Middle  Ear  Catarrh 

438.  Tinnitus  Aurium 

Noises  in  the  head. 

Alcoholism,  Chronic 
Anaemia  of  Brain 
Aneurysm,  Cerebral 
Apoplexy  (praem.) 
Arterio-sclerosis 
Aura  epileptica 
Blow  upon  Head 
Catalepsy  (praem.) 
Cervico-occipital  Neuralgia 
Cholera 

Delirium  Tremens 
Enteric  Fever 
Exophthalmos,  Pulsating 
Foreign  Body 
creaking 

Fracture  of  Base 

Gout 

Herpes  Auris 

swollen  geniculate  ganglion 

Hypertrophy  of  Heart 
Hysteria 
Indigestion  (x) 
Labyrinthine  Disease 

hissing,  humming  or  roaring 

Leukaemia 

Lithaemia 

Malaria 

433-438 


THE   HEARING 


159 


Tinnitus   Atjritjm — continued 
Mania 

Mastoid  Disease 
♦Meniere's  Disease 
Meningitis 
Middle  Ear  Catarrh 
bubbling 

Migraine 
Mumps 

Nephritis,  Chronic 
Neurasthenia 

Obstructed  Eustachian  Tube 
Otitis,  Suppurative 
Otosclerosis 
Plethora 
*Polypus,  Nasal  or  Aural 
Remittent  Fever 
Syphilis,  Labyrinthine 


Tapeworm 

Thrombosis,  Cerebral 
Tumour  of  Brain 
Typhus 
*Wax  in  Meatus 
creaking 

It  also  occurs  in  those  taking 
antipyrin,  ergot,  quinine, 
or  salicylates. 

439.  Fistel-Symptom 

The  patient  being  seated, 
the  nozzle  of  a  Pollitzer 
Bag  is  inserted  into  the 
meatus.  A  slight  com- 
pression of  the  bag  pro- 
duces rotation  of  the 
head  and  eyeballs  fol- 
lowed by  nystagmus. 

Labyrinthine  Fistula 


438-439 


160 


THE  TUNJNG-FORK 


440.  THE  TUNING-FORK 

Two  forks  should  bo  employed,  one  high-pitched,  a  C,  and 
one  low  pitched,  C4.  The  former  is  best  heard  in  obstructive  deaf- 
ness, the  latter  in  nervous  deafness.  Bone  conduction  is  lessoned 
after  60  years  of  age,  and  in  all  cases  of  labyrinthine  disease. 
The  fork  should  be  placed  on  the  middle  of  the  forehead. 


441.  Sound  Increased 

Obstructive  Deafness 
Over-tension   of   Membrane 
or  Ossicles 


442  Sound    Diminished     or 
Absent 

Cerebellar  Abscess 
Nervous  Deafness 

***  In     cerebral     abscess     the 
sound  is  heard  well. 


443.  Positive  Rinne 

(normal  condition) 
The  tuning-fork  placed  op- 
posite the  meatus  is 
still  audible  after  it  has 
ceased  to  be  heard  while 
in  contact  with  the  mas- 
toid process. 


444.  Negative  Rinne 

inaudible  as  above 

Middle  Ear  Disease 


445.  Positive     Weber 
(Weber  +) 

A  C2  tuning-fork  placed  on 
the  forehead  is  heard 
loudest  in  the  deaf  ear. 

Obstructive  Deafness 


446.  Negative    Weber 
(Weber  — ) 

The  tuning-fork  placed  on 
the  forehead  is  heard 
loudest  in  the  sound  ear. 

Nerve  Deafness 


447.  Gardiner-Brown's  Test 

Normally,  the  vibrations  of 
a  tuning-fork  on  the 
mastoid  process  are  felt 
by  trained  fingers  as  long 
as  the  patient  hears 
them.  If  vibrations  are 
heard  after  they  have 
ceased  to  be  felt,  diag- 
nose— 

Middle  Ear  Disease 

If  felt  after  the  patient 
ceases  to  hear  them, 

Internal  Ear  Disease 


448.  Pollitzer's  Test 

A  O'  fork  is  held  before  the 
nares  during  deglutition. 
The  note  is  heard  by  the 
normal  ear  only,  unless 
the  Eustachian  Tube  is 
very  patulous.     Inaudible 


Middle  Ear  Disease 

Eustachian 


with     blocked 
Tube 


440-448 


THE    TUNING-FORK 


161 


449.  Schwabach's  Test 

When  the  C2  fork,  placed 
gently  over  the  patient's 
mastoid  process,  ceases  to 
be  heard,  it  is  instantly- 
transferred  to  the  sur- 
geon's own  mastoid  and 
the  seconds  counted  while 
it  continues  audible.  If 
eight  seconds,  the  note 
would  be '  Schwabach  —  8 ' 
and  the  indication  would 
be — 

Nerve  Deafness. 

In  the  reverse  proceeding, 
the  surgeon  applies  the 
fork  to  his  own  ear  first, 
and  if,  on  its  transference, 
the  patient  hears  for 
eight  seconds  longer  than 


he,  the  note  would  be 
'  Schwabach  -j-  8  '  and  the 
indication  would  be — 

Middle  Ear  Deafness. 


450.  Gelle's  Test 

Siegle's  speculum  is  inserted 
in  the  ear  and  a  vibrating 
tuning-fork  placed  on  the 
mastoid.  This  is  not 
heard  so  well  when  the 
ball  is  squeezed,  owing  to 
increased  tension.  No 
difference  is  noticed  in — 

Ankylosis  of  Stapes 
Otosclerosis 

(For  Nystagmus  Tests,  Eee 
439,  491.) 


M 


< 49-450 


162 


THE    EYES 


THE  EYES 


451.  THE  EYELIDS 

The  skin  of  the  eyelid  is  very  thin  and  its  subcutaneous  tissue 
very  loose ;  hence  the  ease  with  which  it  swells  and  blackens. 
The  upper  eyelid  is  raised  by  the  levator  palpebral  (3rd  nerve), 
aided  to  a  slight  extent  by  the  sympathetic,  which  supplies  Miiller's 
fibres.  Both  lids  are  closed  by  the  orbicularis,  which  is  supplied 
by  the  facial  nerve. 


452.  Eechymosed 
'  Black  Eye ' 

*Blows 

Endocarditis,  Infective 

Fracture  of  Base 

Haemophilia 

Hooping-Cough 

Infantile  Scurvy 

Injuries 

Measles,  Malignant 

Purpura  Hemorrhagica 

Scurvy 
*Straining 

Thrombosis,  Cerebral 

Typhus,  Malignant 

Variola,  Malignant 

Vomiting 

453.  Swollen  Lid 

Ansemia 
lower  lids 
*  Anasarca  (335) 

Angeioneurotic  (Edema 

Arsenic-poisoning 

Cyst  of  Lid 

Dacryocystitis 
*Erysipelas 

Frontal  Sinus  Distension 
upper  lid 


Glanders 

Glaucoma  (x) 

Hay  Fever  (x) 
*Hooping  Cough 

Injuries 

Iodism 

Measles 

Mediastinitis 

Myxcedema 

Retching 
*Stings 
*Stye 

Tenonitis 

Thrombosis 


of     Cavernous 

Sinus 
of  Long.  Sinus 


Trachoma 
Trichinosis 
*Urticaria 
Varicella  (x) 
Variola  (x) 


454.  Darkened  Lids 

Amenorrhea 
*An£emia 

in  dark  persons 

Chlorosis 
Digestive  Troubles 

451-454 


THE   EYES 


163 


Darkened  Lids — continued 
Exophthalmic  Goitre,  I. 
pigmented 

Fatigue 

Hepatic  Colic  (severe) 

Leuoorrhcea 

Menorrhagia 
♦Menstruation 
Phthisis 

455.  Localised  Swellings 
Chalazion 
Dacryocystitis 
Epithelioma 

*Stye 

Tophi,  Gouty 
Trachoma 

'  sago  grain  bodies  ' 

*  Warts 
Xanthelasma 
flat  and  yellow 

456.  Nictitation  (Blinking) 

♦Asthenopia 

Catalepsy,  n. 

Chorea 

Epilepsy 
♦Exophthalmic  Goitre 

Hysteria 

Neurasthenia 
fibrillary 

Paralysis  Agitans 
♦Reflex  Irritation 

worms,  cold,  dentition,  etc. 

Temporal  Caries 
Trigeminal  Neuralgia 
Tumours 

pressing  on  facial  nerve 
(See  Facial  Twitchings, 
405) 


m  2 


457.  Drooping  (Ptosis) 

If  the  eyebrows  are  not  level, 
tho  occipito  -  frontalis 
muscle  should  be  pushed 
down  until  they  are  ;  the 
degree  of  lifting  power 
remaining  is  a  guide  to  tho 
strength  of  the  levator 
muscle. 

Acute    Ascending   Paralysis 
Apoplexy  (x) 
Bulbar  Paralysis 
Cerebro-spinal  Meningitis 
Concussion  of  Brain 
Conium-poisoning 
Diphtheritic  Paralysis 
Exophthalmic  Goitre 
Facial  Hemiatrophy 
♦Facial  Paralysis 

basal 
Gelsemium,  poisoning  by 
Gummata 
Hysteria 

due   to    contracted    orbicu- 
laris 

Locomotor  Ataxy 

Myasthenia  Gravis,  I. 

Neurasthenia 

transient 

Ophthalmoplegia    externa 

Orbital  Disease 

Paralysis  Agitans 

♦Paralysis  of  Third  Nerve  or 

of  Sympathetic 

Ptosis  Congenita 

Syringomyelia 

Tetanus  (x) 

Trachoma,  Old 

Trigeminal  Neuralgia 

Tuberculous  Meningitis 

Tumour  of  Crus 

Vertigo,  Paralysing, 

sudden 

454-457 


164 


THE  EYES 


458.  Sluggish  Re-opening 
Thomsen's  Disease 

459.  Lid  Always    Open 
(Lagophthalmos) 

Contraction  of  Scars 
*Exophthalmic  Goitre 
Facial  Paralysis 
except  when  central 

Landouzy  -  Dejerine    Para- 
lysis 
Leprosy 
Tumour  of  Orbit 

Incomplete  closure  during 
sleep  is  common  in  pro- 
stration from  any  cause. 


460.  Crusted  Edges 
Chromidrosis 

blue 
Eczema 
Intestinal  Irritation 

esp.  from  worms 
Ophthalmia 
Stye 

Sycosis  Tarsi 
*Tinea  Tarsi 


461.  Stellwag's  Sign 

Increase  in  size  of  palpebral 
fissure  out  of  proportion 
to  the  exophthalmos. 

Action  of  Cocaine 
*Exophthalmic  Goitre 
Sympathetic  Nerve  Stimula- 
tion 

462.  v.  Graefe's  Symptom 

The  upper  eyelid  follows  the 
downward  movement  of 
the  eyeball  instead  of 
accompanying  it.  This 
symptom  sometimes  pre- 
cedes the  exophthalmos. 

Action  of  Cocaine 
*Exophthalmic  Goitre 
Sympathetic  Nerve  Stimula- 
tion 

463.  Koeher's  Symptom 

The  surgeon  places  the 
patient's  hand  on  a  level 
with  the  eyes.  On  lifting 
it  higher  still,  the  upper 
lid  springs  up  more  sud- 
denly than  the  eyeball. 

Exophthalmic  Goitre 


464.  THE  CORNEA 


465.  Hazy 

Glaucoma,  Acute 
insensitive 

Keratitis 
Ulceration 

466.  Arcus  Senilis 

A  cloudy  ring  round  the 
cornea.  Of  little  sympto- 
matic value. 


Arterio  -sclerosis 
Fatty  Heart 
*Senility 

467.  Keratitis,  Symptomatic 

Diabetes 

Exophthalmic  Goitre 
Meningitis 

Paralysis,  Trigeminal 
Starvation 

458-467 


THE    EYES 


165 


Keratitis,     Symptomatic  — 
continued 
Syphilis,  Congenital 
interstitial  keratitis 
Tuberculosis 
Tumour  of  Orbit 

468.  Opacities 
Leucoma 

opaque 
Nebula 

semitransluc  ent 

Scars  of  Ulcers,  etc. 
Sclerotitis 

469.  Ulcers 

Fluorescin  (2  per  cent,  with 
sodii  bicarb.  3  per  cent.) 
stains  the  ulcer  green. 

Catarrhal 
Dendritic 

buds  at  the  side  of  a  groove 

Diphtherial 
Gonorrhceal 
Herpetic 

dug  out 
Lagophthalmos  (459) 
Marginal  Ditch  Ulcer 

old  or  debilitated  persons 


Phlyctenular 

children — multiple 

Rodent  Ulcer,  Mooren's 
much  depressed 

Serpiginous 

a  yellow  crescentic  edge 

Simple 

usually  traumatic 

Trachomatous 

Tuberculous 

Ulceration  also  occurs  in 
connection  with  privation 
or  starvation,  and  with 
exposure  due  to  exoph- 
thalmos, or  Fifth  Nerve 
Paralysis.  A  vesicle  in  a 
case  of  variola  or  varicella 
may  leave  an  uloer. 

470.  Corneal  Reflex  Abolished 

(Winking  Reflex) 

Coma  (64) 
Diabetes 

Exophthalmic  Goitre 
Hemiplegia 

affected  side 
Herpes  Frontalis 
Hysteria 
Meningitis 
Paralysis,  Trigeminal 

It  is  usually  present  in  cen- 
tral facial  paralysis. 


467-470 


166 


THE    EYES 


471.  THE  SCLEROTIC   OR   WHITE  OF  EYE 


472.  Pearly 
Addison's  Disease 

*Ana?mia 
Chlorosis 
Nephritis 
Phthisis 

473.  Black  or  Slaty 
Alkaptonuria 
Carboluria 
Ochronosis 


474.  Yellow 
Alcoholism 

*Jaundice  (392) 
Melancholia 
Subconjunctival  Fat 

The  yellowness  is  noticed 
among  workers  in  picric 
acid. 

475.  Bright  Blue 

A  very  rare  hereditary 
condition  associated  with 
fragilitas  ossium. 


476.  THE  CONJUNCTIVA 


Used  here  for  that  portion 
covers  the  white  of  the  eye. 

477.  Dry 

Collapse 

Lagophthalmos  (459) 
Trigeminal  Anaesthesia 

478.  Watery  (Lacrymation) 

Alcoholism,  Chronic 
Asthenopia 
Asthma,  Spasmodic 
Chlorosis 

Conjunctivitis,  Parinaud's 
palpebral  nodules 

*Coryza 

Foreign  Body 

Hay  Fever 

Hooping-Cough,  I. 
*Infiuenza 

Iodism 

Irritants 

Landouzy-Dejerine       Para- 
lysis 

Measles  (early) 

Neuralgia,  Trigeminal 


of  the  mucous  membrane  which 

Typhus  (prodr.) 

The   fungus    of    '  dry    rot ' 
causes  lacrymation. 


479.  Pallid 

Ancemia,  All  forms  of 

(See  385) 

The     lower  lid   should    be 
everted. 

480.  Overflowing   Tears 

(Epiphora) 

Tears    running    down    one 
cheek. 

Abscess  of  Sac 
Blepharitis,  Marginal 
Dacryocystitis 
*Displacement  of  Punctum 
from  scars,  etc. 
Duct,  Obstructed 
,,      Stenosis  of 
Exophthalmic  Goitre 
Facial  Paralysis 
Lupus 

471-480 


THE  EYES 


167 


Overflowing     Tears    (Epi- 
phora ) — continued 
Sclerodermia 
Septum,  Deviate 
Tumours,  Orbital 

481.  Purulent  Discharge 
Abscess  of  Sac 

Con  j  unctivitis — 

Diphtheritic 

Gonorrhceal 

*Simple 

Tuberculous 

482.  Bright  Eyes 
Belladonna-poisoning 

*Delirium 

Exophthalmic  Goitre 
*Flushed  Face  (387) 

Hypersemia  of  Brain 

Hypertrophy  of  Heart 

Mania 

Pleurisy,  Acute 

Pyrexia  (295) 
♦Typhic  State  (62) 

483.  Injected  or  Bloodshot 

Arsenic-poisoning 

*  Conjunctivitis 

diffused  redness  and  tor- 
tuous vessels ;  pressure 
leaves  no  ansemia 

Coryza 

Facial  Paralysis 
♦Foreign  Body 
Glaucoma,  Acute 

both  cilial  and  conjunctival 
vessels  injected 

*Hay  Fever 
Hooping  Cough,  i. 
Influenza 


Iodism 
♦Iritis 

redness  greatest  around 
cornea  ;  vessels  straight ; 
pressure  leaves  an  anaemic 
spot 

Irritating  Gases,  etc. 
♦Measles 

Meningitis  simplex 
Neuralgia  of  Fifth  Nerve 
Pachymeningitis 
Pannus 

484.  Ecchymosed 

Effusion  of  blood  under 
the  conjunctiva.  It  con- 
tinues red  owing  to 
aeration  through  the  thin 
membrane. 

♦Blows 

Epilepsy 

Fracture  of  Base 
♦Hooping  Cough 
♦Straining  or  Vomiting 

Thrombosis    of     Cavernous 
Sinus 

Ulcerative  Endocarditis 

485.  'Sloppy' 

Myxoedema 
Nephritis,  Chronic 

486.  Chemosis 

(Edema  surrounding  the 
cornea. 

Conjunctivitis  (x) 
Gonorrhceal  Ophthalmia 
Ophthalmia  neonatorum  (x) 
Sphenoidal  Sinusitis 
Thrombosis,  Cavernous 


480-486 


168 


THE  EYES 


487.  THE  EYEBALLS 

The  eyeballs  are  moved  by  the  recti  and  oblique  muscles.  During 
sleep  they  are  rolled  upwards  and  outwards,  and  the  same  is  the 
case  in  that  fruitless  endeavour  to  close  the  eyes  in  facial  paralysis 
which  is  known  as  Bell's  Phenomenon. 


488.  Fixed  Eyeballs 

Cavernous  Thrombosis 

Epilepsy,  I. 

*Exophthalmic  Goitre 

Korsakoff's  Syndrome 

as  regards  upward  or  down- 
ward motion 

Locomotor  Ataxy 

Ophthalmophlegia    Externa 

Petit  Mai 

Symblepharon 

Tenonitis 


489.  Nystagmus 

(Oscillating  Eyeballs) 

The  patient  should  be  told 
to  look  quickly  first  to 
one  side  then  to  the  other, 
next  up  and  then  down. 
In  cerebellar  disease, 
the  nystagmus  is  more 
marked  when  the  eyeball 
is  directed  to  the  affected 
side ;  in  labyrinthine,  the 
opposite  side.  Unilateral 
nystagmus  is  usually 
vertical. 

Abscess,   Cerebellar 
rotary 

Albinism 

Amaurosis 

Astigmatism 

Ataxic  Paraplegia 

Bulbar  Paralysis 

Cerebral  Haemorrhage 

Cerebro-spinal   Meningitis 


Chorea 

Choroidal  Disease 
Congenital  Cataract 
Convulsions 
♦Disseminated  Sclerosis 
12  per  cent. 
Friedreich's  Disease 
conjugate 

Hereditary  Cerebellar  Ataxia 
Hydrocephalus,   Chronic 
Hysteria 
Idiocy 
Insanity 

Labyrinthine  Suppuration 
rotary 

Locomotor  Ataxy  (x) 

Meningitis,  Basal 

Microphthalmos 
♦Miner's  Nystagmus 

Multiple  Neuritis 

Myasthenia  Gravis 
♦Neurasthenia 

Optic  Atrophy  (x) 

Opacities  of  Cornea 

Paralysis  of  Eye  Muscle 

of  lateral  rectus,  lateral ;  of 
sup.  or  inf.  rectus,  vertical ; 
of  oblique  muscle,  rotary 

Post-epilepsy 

Primary    Spastic  .Paralysis 

Progressive  Muscular  Atro- 
phy 

Retinal  and  Choroidal  Affec- 
tions 

487-489 


THE  EYES 


169 


Nystagmus — continued 
Spasmus  Nutans 
often  monocular 

Syringomyelia 

Thrombosis    of    Lateral    or 

Cavernous  Sinus 
Tumours  of  Cerebellum,  Crus 

or  Pons 

Nystagmus  is  lateral  in 
50  per  cent,  of  cases ; 
vertical  in  12  ;  rotary 
in  15 ;  circumductory, 
in  2  ;  and  mixed  in  4  per 
cent.  Nystagmus  can 
be  produced  artificially 
by  subcutaneous  injec- 
tions of  lysol,  cresol  or 
chinosol,  and  by  rapid 
rotation  on  a  revolving 
chair.  '  Cheyne's  Nystag- 
mus '  is  graduated  like 
Cheyne-Stokes'  breathing, 
while  in  '  Metronome  Nys- 
tagmus '  the  lateral  move- 
ment is  much  smaller  in 
the  upper  portion  of  the 
globe  than  in  the  lower. 

490.  Bard's  Sign 

When  the  patient  follows 
the  physician's  finger 
from  right  to  left  and 
back  again,  the  oscilla- 
tions increase  in  organic 
nystagmus  and  disappear 
in  the  congenital  form. 


491.  Barany's  Test 

Water  of  temperature  65°  to 
86°  F.  is  syringed  into  each 
ear  separately,  in  slow 
continuous  stream.  Nys- 
tagmus should  appear 
within  20  to  40  seconds. 
A  positive  result  proves 
the  integrity  of  the  vesti- 
bular nerve. 


492.  Protruding      (Exophthal- 
mos or  Proptosis) 

Myopic     eyes    are    usually 
prominent. 

Aneurysm  of  Orbit 

Antral  Distension 

Apoplexy 

Arthritis,     Rheumatoid 

in  children 
Asthma,  Spasmodic 
Carcinoma 
Chloroma 
Cocaine 
Convulsions 
Cysts  of  Orbit 
Delirium  Tremens 
Distension  of  Frontal  Sinus 
Dyspnoea  (1223) 
Encephalocele 
Encephaloid  Cancer 
Epilepsy 

Ethmoid  Cells,  Dilated 
*Exophthalmic  Goitre 

absent  in  25  per  cent. 
Exophthalmos,  Intermittent 

esp.  on  stooping 
Exostosis  of  Orbit 
Fracture  of  Orbital  Plate 
Glaucoma,  Acute  (x) 
Glioma 

Gumma  of  Orbit 
Hydatids  of  Orbit 
Hydrocephalus 
Hypertrophy  of  Heart 
Infantile  Scurvy 
Intranasal  Growth 
Lacrymal   Gland,    Enlarged 
Leontiasis  Ossea 
Lymphadenoma 
Lymphatic  Leukaemia 
Meningocele 

489-492 


170 


THE  EYES 


Protruding — con  tinned 
Myopia,  in. 
Nephritis,  Chronic 
Ophthalmoplegia 
Orbit,  Tuberculous 
Orbital  Cellulitis 

,,      Periostitis 
Paralysis  of  Third  Nerve 
Pulsating  Exophthalmos 

from  blows,  etc. 
Retrobulbar   Haemorrhage 
Scurvy  (x) 
Sphenoidal  Sinusitis 
Stimulation  of  Sympathetic 
Tenonitis 

Thrombosis     of     Cavernous 
Sinus 
,,  of    Superior 

Longitudinal  Sinus 
Thymus,  Enlarged 
Tumour  of  Antrum 
„       of  Optic  Nerve 
,,       of   Orbit 
Varix  of  Orbit 
only    on    stooping    or    on 
pressing     upon     internal 
jugular  vein 

Vomiting,  Persistent 

493.  Sunken     Eyes 
(Enophthalmos) 
Atrophy  of  Eyeball 
Cancerous  Cachexia 
*  Cholera 
Collapse  (235) 
*Diabetes 
*Diarrhcea 
Dysentery 
Enteric  Fever 
Facial  Hemiatrophy 
one  only 

Haemorrhage 


Malformation,   Congenital 
Orbital  Scars 
Paralysis  of  Sympathetic 
*Phthisis 

*  Wasting  Diseases  (311) 

494.  Enlarged  Orbit 

Real  or  apparent. 

*Abscess 
Aneurysm 

*  Cancer 
Exostosis 
Glioma 
Hydatids 

Lacrymal   Gland,    Enlarged 
Leontiasis    Ossea 

495.  Strabismus  (Squint) 

Squint  is  of  two  kinds : 
when  spasmodic,  the 
affected  eye  follows  the 
sound  eye  in  its  move- 
ments ('  concomitant '), 
and  is  always  evident ; 
when  paralytic,  the 
squint  may  only  be 
evident  when  the  patient 
tries  to  look  in  the 
direction  of  the  paralysed 
muscle.  In  this  form 
the  affected  eye  does  not 
follow  the  movements 
of  the  other,  and  dip- 
lopia is  usually  present. 
Convergent  squint  is 
generally  associated  with 
hypermetropia ;  diver- 
gent, with  myopia. 

Acute  Ascending  Paralysis 
Diphtheritic  Paralysis 
Facial  Hemiatrophy 
„      Paralysis 
(basal) 
Flatulence  (Infants) 
Gout  (x) 
Haemorrhage,  Cerebral 

492-495 


THE   EYES 


171 


Strabismus    (Squint)  —  con- 
tinued 
*Hooping  Cough 
Hydrocephalus 
Hyperrnetropia 
Hysteria 

never  divergent 
Lesion  of  Pons 

double  convergent 
Locomotor  Ataxy 
Meningitis 

IMigraine   Ophthalmologique 
Ophthalmoplegia  externa 
*Paralysis    of    Third    Nerve 
(1308) 
external 
*Paralysis    of    Sixth    Nerve 
(1311) 
internal 
Spasm  of  Muscles 
Syphilitic  Deposits 
Syringomyelia  (x) 
Trigeminal  Neuralgia  (x) 
*Tuberculous  Meningitis 
Tumour  of  Brain 
Tumour  of  Cerebellum 

usually  convergent,  but 
sometimes  showing  'skew 
deviation,' i.e.  one  up  and 
one  down 

496.  Conjugate  Deviation 

Both  eyes  persistently 
turned  in  one  direction — 
towards  the  lesion  side  if 
paralytic ;  towards  the 
opposite  side  if  irritative. 
In  lesions  of  the  pons, 
however,  the  reverse  is  the 
case. 

497.  Ophthalmoplegia 

Due  to  simultaneous  pres- 
sure upon  the  third, 
fourth,  and  fifth  nerves, 
or  to  nuclear  disease. 


Bulbar  Paralysis 
Encephalitis 
Meningitis,  Basic 
Neurasthenia 

transient 
Neuritis,  Alcoholic 

,,  Diphtheritic 

,,  Lead 

„  Rheumatic 

Syphilis 

498.  Moebius'  Sign 

Insufficient  convergence  to 
accommodation. 

Exophthalmic   Goitre 

499.  Dixon  Mann's  Sign 

One  eye  appears  to  be  on  a 
lower  level  than  the  other. 

Exophthalmic   Goitre 
Tachycardia 
*#*  Exclude      malformations, 
facial    hemiatrophy,    etc. 

500.  Oeulo-Cardiac  Reflex 

The  eyeballs  are  compressed 
for  from  30  to  90  seconds. 
Normally  the  pulse  should 
be  slowed  by  from  6  to  8 
beats  per  minute. 

Absent  in : 

Locomotor  Ataxy 
Excessive  in : 

Bradycardia,  Nervous 
Gastric  Neuroses 

it  sometimes  causes  vomit- 
ing 

Goitre,  Exophthalmic 
Rheumatism,  Articular 
Syphilis 
Tuberculosis 
The    reflex    is    normal    in 
myocardial  bradycardia. 

495-500 


172 


THE  PUPILS 


501.  THE  PUPILS 

The  iris  regulates  the  amount  of  light  admitted,  shuts  off  the 
side  rays,  and,  during  accommodation,  supports  the  action  of  the 
ciliary  muscle.  The  dilating  or  radiating  fibres  are  supplied  by 
the  cervical  sympathetic,  the  contracting  or  circular  by  the  third 
nerve.  When  the  pupils  are  unequal  ('  anisocoria  '),  the  less  mobile 
is  usually  the  abnormal  one.  In  adults  the  pupil  should  be  4  mm. 
in  diameter  ;  in  old  age  it  is  smaller. 


Pupils  Dilated 
(Mydriasis) 

502.  One  Dilated 

Aneurysm  of  Aorta 

,,  of  Innominate 

Cataract 

Choroid  Disease 

General  Paralysis 
*Glaucoma 

Lens,  Dislocation  of 
*Paralysis  of  Third  Nerve 

Pleural  Effusion 
same  side 

Sympathetic,  Stimulation  of 
Tuberculous  Meningitis 
Tumour  of  Brain 
,,      of  Neck 


503.  Both  Dilated 

Acute  Yellow  Atrophy 
Alcoholic   Coma 
Amaurosis 
*An8emia 

,,        of  Brain,  n. 
Aortic  Regurgitation 
Apoplexy  (profound) 
Asphyxia 
Catalepsy 

Concussion  of  Brain 
Dementia,  Acute  Primary 


Diabetic  Coma 
Diphtheritic  Paralysis 
Dyspnoea 
Emotion,  Strong 
esp.  fear 

Epilepsy,   n. 
Glaucoma 
fixed  and  greenish 

Hydrocephalus 
Hysteria 
Melancholia 
Meningitis,  Simplex,  II. 

,,  Tuberculous,  u. 

Myelitis,  Acute 

cervical  portion 

Myopia 

Nausea 

Neurasthenia 

Nitrous  Oxide 

Pain,  Acute 

Ptomainism 

Stupor 

Sunstroke,  II. 

Syncope 

Thrombosis,  Cerebral 

Trance 

Action  of — 

Aconite,  n. 

Adrenin 

Alcohol 
*Belladonna 

501-503 


THE  PUPILS 


173 


Both  Dilated — continued 
Action  of — 
Chloroform 
Chloral 
Cocaine 
Conium 
Cyanides 
Duboisine 
Hyoscyamus 
Pituitrin 
Stramonium 
Tobacco 

Pupils  Contracted 
(Myosis) 

504.  One  Contracted 

Amaurosis  of  Spinal  Origin 
Aneurysm  of  Aorta  (x) 
Cerebral  Haemorrhage 
Fracture  of  Base 
*General  Paralysis 
Iritis 

Klumpke's  Paralysis 
Lesion  of  Cord 

Eighth    cervical    and    first 
dorsal   segments. 

Locomotor  Ataxy  (x) 

Migraine 

Paralysis  of  Sympathetic 

Sclerotitis 

Syringomyelia 

Tumour  of  Neck 

505.  Both  Contracted 
Anaemia  of  Brain,  I. 
Apoplexy 

Caries,  Cervical 
Cerebral  Hyperemia 
*       „        Irritation 
Compression  of  Brain,  I. 


Concussion  of  Brain,  in. 
Delirium  Tremens 
Haematoma  of  Dura  Mater 
Haemorrhage      into      Pons, 

Cerebellum,    or   Ventricle 
Hypermetropia 
Iritis 

adhesions 

Locomotor  Ataxy 
Mania 
Meningitis,  I. 

„  Cerebro-spinal 

Mitral  Stenosis 
*Morphinism 
Photophobia  (561) 
Retinitis 
Sleep,  Healthy 
Sunstroke,  I. 

Tuberculous  Meningitis,  i. 
Typhus 
Uraemia 
immobile 

Action  of — 
Aconite,  I. 
Opium 
Physostigma 

506.  Margin  Irregular 
Adhesions 
General  Paralysis,  I. 

oval   (Berger's   Sign) 
Glaucoma,  Acute 

oval 

*Iritis,  Rheumatic 

„       Syphilitic 
Lens,  Dislocated 
Locomotor  Ataxy 

oval 

Pupillary    Membrane,    Per- 
sistent 

503-506 


174 


THE  PUPILS 


Margin    Irregular  —  cont. 
Synechia,  Anterior 
Third  Nerve  Paralysis  (x) 
Trauma 

notched   and    dilated    from 
rupture  of  pupillary  edge 


507.  Iridodonesis 

(Iris  Tremulous) 
Dislocation  of  Lens 

partial  or  complete 
Liquefaction  of  Vitreous 


508.  PUPIL  REFLEXES 

In  examining  the  pupils  for  a  reflex,  care  must  be  taken  that 
the  effects  of  light  and  accommodation  do  not  clash.  Thus  the 
lamp  should  be  held  about  a  yard  away  for  the  light  reflex  and  the 
eyes  must  be  turned  away  from  the  light  for  the  accommodation 
reflex. 

There  are  four  normal  pupil-reflexes  :  two  contracting — namely, 
light  and  accommodation ;  and  two  dilating — sensory  and  psychic. 
The  pupil  centre  is  in  the  corpora  quadrigemina. 


509.  Sluggish  to  Light 

The  light  reflex  is  ascer- 
tained by  covering  the 
eyes  with  the  hand,  a 
bright  light  being  in 
front ;  then  suddenly 
removing  one  hand  at  a 
time  and  noting  the 
rapidity  with  which  the 
pupil  contracts.  While 
one  eye  is  under  examina- 
tion, the  other  must  be 
covered  (see  510). 

Aneurysm 
Apoplexy 
Asphyxia 
Atrophy  of  Brain 
Cataract 

Cerebral  Tumour 
Coma  (64) 

Compression  of  Brain 
Epilepsy,  n. 
Hydrocephalus 

„  Spurious 

Hysteria  (x) 


*Meningitis,  n. 

Ophthalmoplegia  interna 

Optic  Atrophy  (539) 
„     Neuritis  (538) 
*Paralysis  of  Third  Nerve 

Phthisis  (x) 

Pleurisy 

Retinitis,  n. 

Syringomyelia 

Tumour,  Intrathoracic 
of  Brain 


510.  Consensual  Reflex 

Light  directed  to  one  eye 
should  cause  some  con- 
traction of  the  opposite 
pupil. 

Absent    in — 

Lesions     of     Optic     nerve, 
chiasma  or  tract. 

Care  must   be  taken  to 
shade  the  other  eye. 

506-510 


PUPILS 


175 


511.  Gower's  Sign 

Intermittent  and  abrupt, 
but  not  rhythmical,  oscil- 
lation of  the  iris  under 
the  influence  of  light. 

Locomotor  Ataxy 

very  early 

512.  Hippus 

Rhythmical  oscillation  of 
the  pupil  on  exposure  to 
light  independently  of 
respiration. 

Alcoholism 
Chorea 

Disseminated  Sclerosis 
Epilepsy 

General  Paralysis 
*Hysteria 
Leptomeningitis 
Meningitis 
Neurasthenia 
Rheumatism,  Acute 
Scotoma 
Spasmus  Nutans 

Respiratory  oscillation  is 
well  seen  in  Cheyne- 
Stokes'  breathing. 

513.  Sanger's  Pupil  Reaction 

The  light  reflex  returns  after 
a  short  stay  in  the  dark. 
Present  in  Cerebral  Syph- 
ilis. 
***  Absent  in  Locomotor  Ataxy. 

514.  Hemiopie    Pupillary    Re- 
action (Wernicke's  Sign) 

If  the  pupil  reacts  when  the 
light  falls  upon  the  blind 
half  of  the  retina,  the 
lesion  is  posterior  to  the 
corpora  geniculata.  If  it 
does  not  react,  the  lesion 
is  anterior  to  these  bodies. 

Hemiopia  (547) 


515.  Paralysis  of  Accomoda- 
tion (Accommodation  or 
Convergence  Reflex) 

This  is  ascertained  by  direct- 
ing the  patient  to  look 
first  at  a  distant  object 
and  then  at  the  surgeon's 
finger,  which  is  held  six 
inches  away.  The  result 
should  be  contraction  and 
convergence.  The  accom- 
modation muscles  are  all 
supplied  by  the  third 
nerve. 

*Atropine 

Blow  on  Eyeball 

Diabetes 

Diphtheritic  Paralysis 

Exposure  to  Cold 

Influenza 

Neuritis 

Paralysis  of  Third  Nerve 
ciliary  muscle 
*Syphilis 

516.  Argyll-Robertson  Pupil 

The  pupils  react  to  accom- 
modation but  not  to  light. 
It  is  suspicious  of  old 
syphilis. 

Ataxic  Paraplegia 

Choroiditis 

Diabetic  Sclerosis 
*General  Paralysis  of  Insane 

Hemiplegia  (x) 

Hereditary  Cerebellar  Ataxy 

Hydrocephalus 

Lead-poisoning 
*Locomotor  Ataxy 

Ophthalmoplegia,  Nuclear 

Progressive  Muscular  Atro- 
phy 

Senile  Brain  Atrophy 
511-516 


176 


PUPILS 


Argyll -Robertson  Pupil — 

continued 

Syphilitic  -Meningitis 

***  Argyll-Robertson  Pupil  is 
present  temporarily  in 
the  acute  infections. 

517.  Reversed  Argyll-Robertson 

The  pupil  reacts  to  light, 
but  not  to  accommoda- 
tion (Rare). 

Basal  Meningitis 

Myelitis 

Syphilis 

Tumour  of  c.  quadrigemina 

518.  Bechterew's     Paradoxical 
Pupil  Reflex 

The  pupil  dilates  to  light 
(Rare). 

General  Paralysis 
Locomotor  Ataxy 

519.  Westphal's  Pupil  Pheno- 
menon 

The  examiner  holds  the  lid 
forcibly  open  while  the 
patient  tries  to  close  the 
eye.  The  pupils  then 
contract. 

General  Paralysis 
Hysteria  (x) 
Locomotor  Ataxy 

520.  Piltz'  Sign 

When  the  lids  fail  to  close 
the  eyes,  the  pupils  con- 
tract. 

Epilepsy 

25  per  cent. 

General  Paralysis 

Locomotor  Ataxy 


521.  Gifford's  Pupil  Reflex 

On  trying  to  close  the  lids 
against  the  will  of  the 
patient  the  pupils  con- 
tract. 

General  Paralysis 

Locomotor  Ataxy 

Partial  Blindness 

when  due  to  retinal  or  optic 
nerve  lesions 


522.  Cilio-Spinal  Reflex 

Pinching  the  skin  of  the 
check  or  neck  causes 
dilatation  of  the  pupil. 

Absent  in — 
Adhesions 
'  Cervical  Cord  Lesion 

,,        Sympathetic  Lesion 
General  Paralysis 
Glaucoma 
Locomotor  Ataxy 


523.  Bumke's  Psychic  Pupil 

Dilatation    in    response    to 
psychical  stimuli. 

Absent  in — 

Cervical  Sympathetic,  Para- 
lysis of 
Dementia  Precox 


524.  Loewi's  Symptom 

Adrenalin  causes  marked 
dilatation  of  the  pupils 
within  an  hour.  The  solu- 
tion instilled  is  adrenalin 
chloride  1  in  1000. 

Exophthalmic  Goitre  (x) 
Pancreatic  Diabetes 
Pancreatitis 

516-524 


PUPILS  177 


525.  THE  TENSION 

The  surgeon  presses  on  the  eyeball  through  the  upper  lid,   the 
patient  looking  down. 

Degrees  are  expressed  by  +  or  —  1,  2,  or  3. 


526.  Increased    (T   -f  ) 
Glaucoma 
Lens,   Dislocated 
Sclerotitis,  n. 


527.  Diminished  (T  —  ) 

Cervical  Sympathetic  Para- 
lysis 
Detached  Retina 
Loss  of  Vitreous  Humour 
*+*  Tn  diabetic  coma  the  eyeball  is  non-elastic  and  oedematous. 


n  525-527 


178 


THE   OPHTHALMOSCOPE 


528.  THE  OPHTHALMOSCOPE. 

To  examine  the  fundus  oculi  with  the  ophthalmoscope,  the 
pupil  should  if  possible  be  previously  dilated  with  a  few  drops 
of  homatropine  solution  ;  the  patient  being  seated  in  a  darkened 
room,  and  a  bright  light,  provided  with  a  lens,  placed  on  his 
left  side,  on  a  level  with,  and  a  little  behind,  his  eyes.  The 
observer  sits  facing  him  on  a  somewhat  higher  chair,  about  two 
inches  only  separating  his  eye  from  that  of  the  patient.  Then 
having  fitted  the  ophthalmoscope  with  an  appropriate  lens,  he 
looks  through  the  hole,  holding  the  mirror  at  such  an  angle  as  to 
throw  a  beam  of  light  upon  the  patient's  eye.  This  is  the  direct 
method.  In  the  indirect  examination  a  space  of  18  to  20  inches 
should  intervene  between  the  two  heads.  The  observer  holds 
a  lens  of  one-  or  two -inch  focus  in  front  of  the  patient's  eye 
with  the  finger  and  thumb  of  the  disengaged  hand,  and  steadies 
it  by  resting  the  remaining  fingers  on  his  forehead.  To  see  the 
optic  disc  the  patient  is  told  to  fix  his  gaze  upon  the  tip  of  the 
surgeon's  more  distant  ear,  and  the  observer  by  means  of  a 
slight  circumductory  motion  of  the  lens  is  able  to  inspect  the 
entire  fundus.  The  yellow  spot  is  best  seen  by  directing  the 
patient  to  look  through  the  hole  in  the  mirror  ;  assistance 
may  be  obtained  from  most  sitters  by  telling  them  to  turn  their 
gaze  in  specified  directions.  At  the  conclusion  of  the  examina- 
tion a  drop  of  a  1  per  cent,  solution  of  eserine  should  be  instilled, 
otherwise  the  patient  will  be  half  blind  for  the  rest  of  the  day. 
Sometimes  cocaine  solution  will  suffice  for  dilatation  ;  its  action 
passes  off  much  more  quickly  than  that  of  atropine.  I  have 
recently  availed  myself  of  the  cilio-spinal  reflex  (522)  to  dilate 
the  pupil  for  retinal  examination,  and  with  considerable  success. 
I  have  not  heard  of  this  having  been  done  before. 


529.  Reflected  Redness 
Absent  in — 

Cataract 
Leucoma 
Opacity  of  Vitreous 

530.  Retinal  Haemorrhages 

When  fresh,  they  are 
bright  red ;  later  they 
become  yellowish  or  pig- 


mented, and  they  may 
finally  disappear  without 
leaving  a  trace. 
When  arising  from  venous 
engorgement  or  blood 
changes,  there  may  be  no 
rupture  of  the  vessel 
(diapedesis). 

Ague 

Amyloid  Kidney  (x) 

Anaemia  (x) 

528-530 


THE   OPHTHALMOSCOPE 


179 


Retinal      Hemorrhages  — 
continued 
Arterio-sclerosis 

preceded  by  thickening  of 
the  arteries  and  narrow- 
ing of  the  veins 

Cerebral  Haemorrhage     (x) 
♦Cirrhosis  of  Kidney 
Contusion  of  Eyeball 
Diabetes 
Embolism 

Endocarditis,  Ulcerative 
Gout 

Haemophilia 
Heart  Disease 
Hypertrophy  of  Heart 
Leukaemia 
Malarial  Fevers 
Menopause 
Menses,  Suppressed 
Nephritis,  Chronic  (x) 
Optic  Neuritis  (53S) 

striae  on  disc 
Pernicious  Anaemia 

flame-shaped 

Purpura 

Pyaemia 

Scurvy 

Syphilis 

Thrombosis 

Wound  into  Vitreous 

Violent  coughing  or  vomit- 
ing will  sometimes  cause 
haemorrhage. 


531.  Arterial  Pulsation 

Aortic  Regurgitation 
Exophthalmic  Goitre 
Hyperaemia  of  Brain 
Hypertrophy  of  Heart 


532.  Black   Spots    or   Patches 
on  Retina 

Choro-Retinitis 
Disseminated  Choroiditis 
Retinitis  Pigmentosa 

like  bone  corpuscles 
Rupture  of  Choroid 

at  margins  of  a  white  streak 

Thrombosis    of    Vena    Cen- 
tralis 

vessels  white  and  radiating 


533.  White  Spots  or  Patches 
Albuminuric  Retinitis 

star-shaped — near  macula 
Coloboma  of  Choroid 

a  single  large  patch  below 
the  disc 

Detachment  of  Retina 
large  tremulous  patch 

Diabetes  (x) 

Disseminated  Choroiditis 
Opaque  Nerve  Fibres 
Rupture  of  Choroid 
a  large  white  crescent 

Syphilitic  Retinitis 
Tubercle  of  Choroid 


534.  Dilated  Veins 

Albuminuric  Retinitis 
Glaucoma 
Optic  Neuritis 
tortuous 

Purpura  Haemorrhagica 
n  2  530-534 


180 


THE    OPHTHALMOSCOPE 


535.  Contracted  Arteries 

Albuminuric  Retinitis 
Embolism   of   Arteria   Cen- 
tralis 

a  pale  area  around  disc  and 
a  cherry  red  spot  near 
macula 

Optic  Atrophy,  in. 
„     Neuritis 

536.  *  Silver   Wire  Arteries  ■ 
due  to  degeneration  of  walls 

Arterio  -sclerosis 
Granular  Kidney 

537.  Shadow  Sign 

On  tilting  the  concave 
mirror  laterally,  the 
shadow  moves  in  the  same 
direction  as  the  mirror 
in  myopia ;  hut  in  the 
opposite  direction  in 
emmetropia  and  hyper  - 
metropia.  It  moves 
differently  in  different 
meridians  when  astig- 
matism is  present. 

538.  Optic  Neuritis 

Veins  tortuous ;  periphery 
of  disc  blurred.  In  uni- 
lateral lesions  the  disc 
is  most  swollen  on  the 
affected  side. 

Vision  not  necessarily 
affected.  The  advanced 
form  is  termed  '  Choked 
Disc' 

Abscess   of    Brain  or  Cere- 
bellum 
Amenorrhcea  (x) 
Anaemias,  Severe 
Aneurysm  in  Brain 
Caisson  Disease 


Caries  of  Sphenoid 

Cerebro -spinal  Meningitis 

Chlorosis 

Cirrhosis  of  Kidney 

Diphtheria 

Effusion  at  Base 

Exhaustion 

Facial  Paralysis 

basal 
Hereditary  Cerebellar  Ataxy 
Hydrocephalus 
Lead-poisoning 
Leukaemia 
Meningitis,  Syphilitic 

,,  Traumatic 

*Meningitis,  Tuberculous 

50  per  cent. 
Myelitis,  Acute  (x) 

of  cervical  portion  of  cord 
Node,  Intracranial 
Pachy  meningitis 
Prolonged  Lactation 
Syphilis 
Tumours  of  Brain 

„         of  Cerebellum 

The  symptom  is  often 
absent  in  tumours  of 
pons,  medulla  or  corpus 
callosum. 

539.  Optic  Atrophy 

Alcoholism,  Chronic 
Choroiditis,  Chronic 
♦Diabetes 
Disseminated  Sclerosis 
Friedreich's  Disease  (x) 
General  Paralysis,  n. 
Glaucoma 

Hereditary  Cerebellar  Ataxy 
Hydrocephalus 
Intra-ocular  Haemorrhage,!!. 

535-5 


THE   OPHTHALMOSCOPE 


181 


Optic  Atrophy — continual 
Lead -poisoning 
Locomotor  Ataxy 

10  per  cent,  (disc  mottled) 
Meningitis  (x) 
Retinitis  Pigmentosa 
Tobacco  Amaurosis  (x) 
*Tumour  of  Brain 

Organic  arsenical  com- 
pounds are  liable  to  in- 
duce it. 

540.  Cupped  Disc 

Atrophy  of   Optic  Nerve 

*Glaucoma 

Slight  cupping  is  physio- 
logical. 


541.  Disc  Blurred 

Albuminuric  Retinitis 
Optic  Atrophy  (539) 
Optic  Neuritis  (538) 

and  enlarged 
Syphilitic  Retinitis 


542.  Tubercles  on  Choroid 
Acute  Miliary  Tuberculosis 
Tuberculous  Meningitis 


543.  Exudative  Choroiditis 
Cerebro-spinal  Meningitis 
Syphilis 


539-543 


182 


THE  VISION 


544.  THE  VISION 

The  sight  centre  is  in  the  lingual  and  fusiform  lobes  and  the  cuncus. 
Normal  vision  is  termed  Emmetropia.  In  Myopia,  or  short  sight, 
the  eyeball  is  elongated  so  that  the  rays  are  focussed  in  front  of 
the  retina.  In  Hypermetropia  the  eyeball  is  too  short  and  the 
rays  are  focussed  behind  the  retina.  In  Presbyopia,  which  begins 
between  38  and  45,  the  lens  is  denser  and  the  ciliaris  weaker. 

In  using  Test  Types  for  estimating  vision,  V  =  Visual  Acuity ; 
D  =  the  normal  distance  at  which  a  given  sized  type  should  be 
legible  ;  d  =  the  distance  of  the  eye  from  the  type.  In  graphic 
representation  d  is  the  numerator.     Thus  normal  vision  for  type 

readable  at  6  metres  is  V  =  -  -  or  — ;  but  if  at  that  distance  the  patient 

D       b  6 

can  only  read  the  18-metre  type,  the  formula  would  be  V  =  y^. 


545.  Diplopia  (Double  vision) 

To  determine  to  which  eye 
each  picture  belongs,  a 
spectacle  frame  with  a 
red  and  a  blue  glass 
should  be  employed.  If 
the  left  picture  belongs  to 
the  right  eye  the  diplopia 
is  termed  '  crossed,'  if  to 
the  left  eye,  homonymous. 

Crossed  diplopia  is  associ- 
ated with  divergent 
squint ;  homonymous 
with  convergent. 

Alcoholism 
Asthenopia,  Muscular 
Diphtheritic  Paralysis 
Disseminated  Sclerosis 
Friedreich's  Disease 
Locomotor  Ataxy 
Myasthenia  Gravis 
Ophthalmoplegia  externa 
v/  Orbital  Abscess,  Growth,  or 
Haemorrhage 
Paralysis  of : 

External  Rectus 

false  image  outside 
true  one ;  diplopia 
on  looking  outwards 

Internal  Rectus 

two  objects  level;  false 
inside  true. 


Paralysis  of  : 

Superior  Rectus 

false  above  true 
Inferior  Rectus 

false  below  true 

Superior  Oblique 

false  image  below, 
and  to  outer  side, 
diplopia  only 
present  when  the 
patient  looks  down 

Inferior  Oblique 

diplopia  on  looking  up, 
false  image  above 
and  to  outer  side. 

Tumour  of  Brain 

Also  in  poisoning  by  bella- 
donna, conium,  and  gel- 
semium. 


546.  Diplopia,  Monocular 

The  object  appears  double 
even  when  one  eye  is 
shut. 

Astigmatism 
Cataract,  Incipient 

or  polyopia 
Dislocation  of  Lens 
Tumour  of  Brain 

544-546 


THE  VISION 


183 


547.  Hemiopia 

The  lesion  is  in  tho  posterior 
portion  of  the  internal  cap- 
sule on  the  side  opposite 
to  that  of  the  blind  half. 

If  both  right  or  both  left 
halves  are  affected,  it  is 
termed  homonymous ;  if 
both  inner  or  both  outer 
halves,  heteronymous. 
The  term  '  Altitudinal ' 
is  applied  when,  as  rarely 
happens,  the  upper  or  the 
lower  half  of  the  visual 
field  is  involved. 

Abscess,  Cerebral 

Acromegaly 

Aura  epileptica 

Gout  (x) 

Gumma 

Hysteria 

Lithsemia 

Migraine  (x) 

Neurasthenia 

Rupture  or  Occlusion  of 
Posterior  Cerebral  Artery 

Tumour  of  Posterior  part  of 
Internal  Capsule,  Optic 
Chiasma,  Optic  Tract, 
Occipital  Lobe  or  Pituit- 
ary Body. 

Hemiopia  is  often  associ- 
ated with  visual  aphasia. 

(See  Wernicke's  Sign,  514) 

548.  Contraction     of      Visual 
Field 

The  patient  will  often  say 
that  his  sight  is  like 
'  looking  through  a  tube.' 

The  visual  field  should  be 
estimated  by  the  peri- 
meter, but  a  2^-inch  ring 
held  at  different  distances 
answers  fairly  well,  the 
patient  being  required  to 


say  whether  he  sees  any- 
thing outside  it  or  not. 
The  ring  can  be  formed 
with  the  fingers. 

Ataxia,  Cerebellar 
Choroiditis,  Exudative 
Choro-retinitis  Pigmentosa 
Detached  Retina 
Disseminated  Sclerosis 
Embolism  of  Cerebral  Artery 
Foreign    Body    in    Cornea, 

Lens,  or  Vitreous 
Glaucoma 
Hemorrhage    into    Retina 

*Hysteria 
Injuries  to  Eyeball 
Nyctalopia 

*  Opacities  in  Cornea,  Lens,  or 
Optic  Atrophy         [Vitreous 
Raynaud's  Disease 
Retinitis  Pigmentosa 
Rheumatoid  Arthritis 
Scotoma 
Syringomyelia 
%*  The  colour  field  is  sometimes 
contracted,    especially   in 
hysteria. 

549.  Chromatopsia   or   Colour 
Blindness 

Red  Blindness  and  Blue 
Blindness  are  the  com- 
monest forms. 

Congenital  Defect 

Hysteria 

Kidney,  Cirrhosis  of 

blue 
Neurasthenia 
Optic  Atrophy 

,,     Neuritis 
Tobacco  Amaurosis 

Hemic  hromatopsia  some- 
times occurs. 

547-549 


184 


THE  VISION 


550.  Central  Scotoma 

If  the  central  patch  of 
blindness  is  unilateral, 
it  is  due  to  disease  of  the 
choroid  or  retina  near  the 
macula. 

Alcoholism 

Haemorrhage,  Macular 
*Tobacco  Amaurosis 

551.  Nyctalopia  or  Day-blind- 
ness) 

The  names  here  given  for 
night-  and  day-blindness 
are  sometimes  incorrectly 
reversed. 

Albinism 
Snow- blindness 
Tobacco  Amaurosis 

552.  Hemeralopia  (Night-blind- 
ness) 

Ague 

Choroido  -retinitis 

Keratomalacia 

Nephritis 

Retinitis  Pigmentosa 

Scurvy 

553.  Muscae  Volitantes  (Black 

specks) 

The  patient  should  be  made 
to  look  at  a  white  surface. 
The  motion  is  upward 
when  the  cause  is  in  the 
vitreous. 

Anaemia  of  Brain 
Cholera 

Cataract  (praem.) 
Duodenal  Catarrh 
Haemorrhage 
Hyperaemia  of  Brain 
Hypertrophy  of  Heart 


Hysteria 
*Liver  Disorders 
Opacities  of  Vitreous 
Tumour  of  Brain 

554.  Rainbow  Edges  to  Objects 
The    phenomenon    is    due 

not  to  tension,  but  to 
disturbance  of  the  corneal 
epithelium. 

Congestive  conditions  (x) 
Conjunctivitis 
with  thin  layer  of  mucus 
*Glaucoma 

555.  Green   Vision 

Cinchonism  (x) 

556.  Cyanopia  or  Blue  Vision 

Alcoholism 
Cataract 
following  upon  operation 

557.  Erythropia  or  Red  Vision 

Cataract 
following  operation 

Retinal  Haemorrhage 
Snow-blindness 
Vitreous  Haemorrhage 

558.  Xanthopia  (Yellow  Vision) 

Jaundice 

Santonin,  amyl  nitrite,  can- 
nabis indica,  picric  acid 
or  quinine  may  cause  it. 

559.  Sparks  or  Flashes 
Apoplexy  (praem.) 
Aura  epileptica 
Delirium  Tremens 
Epilepsy 

550-559 


THE  VISION 


185 


Sparks   or    Flashes  —  con- 
tinued 
Hyperemia  of  Brain 
Hypochondriasis 
Hysteria 
Insanity 
Meningitis 
*Migraine 

1  wavy  glimmer '  or  '  fortifi- 
cation figures ' 

Neurasthenia 
Thrombosis,  Cerebral 
Tumour,  Cerebral 
csp.  of  occipital  lobe 


560.  Garel's  Sign 

Luminous  perception  on  the 
sound  side  only,  when  an 
electric  torch  is  placed  in 
the  buccal  cavity  (see  6U2). 

Empyema  of  Antrum 


561.  Photophobia  (Intolerance 
of  Light) 

Anaemia  of  Brain 

Arsenic-poisoning 

Cerebro -spinal  Meningitis 

Choroiditis 

Cinchonism 
*Conjunctivitis 

Cyclitis 

Encephalitis 

Gastritis,  Acute  (x) 

Hooping  Cough,  I. 

Hyperemia  of  Brain 

Hypertrophy  of  Brain 

Hysteria 
*Iritis 

Keratitis 
*Measles,  I.,  and  praam. 


Meningitis,  i. 
*  Migraine 

Neuralgia,  Trigeminal 

Neurasthenia  (x) 
*Retinitis 

Snow- blindness 

Trichinosis 

Typhus  (praem.) 

Ulcer  or  Vesicle  of  Cornea 


562.  Amblyopia 

Feeble  sight  without  change 
in  the  fundus. 

Acromegaly 

Alcoholism  (x) 

Atrophy  of  Brain 

Bromism 

Cinchonism  (x) 

Diphtheritic  Paralysis 

Haemorrhage 

Hereditary  Cerebellar  Ataxy 

Hydrocephalus 

Leontiasis  Ossea 

Locomotor  Ataxy 

Mercurialism 

Migraine 

Neurasthenia 

Salicism 

Syringomyelia  (x) 

Tumour  of  Brain 

Tobacco  or  even  tea,  in 
excess,  will  produce  a 
transient  form. 


563.  Crossed  Amblyopia 

The  lesion  is  in  the  opposite 
half  of  the  brain. 

Haemorrhage,  Cerebral 
Hemianaesthesia,  Hysterical 
559-563 


186 


THE  VISION 


564.  Macropia  and  Micropia 

The   object   appears   larger 
or  smaller  than  it  really  is. 

Delirium,  Infantile 
Epilepsy 

Fatigue  of  Retina 
Haschish  Poisoning 

565.  Amaurosis    or    Blindness 
from   extra-ocular  causes 

Alcoholism 

Amaurotic  Family  Idiocy 
Amenorrhcea 
Anaemia  of  Brain 
transient 

Cerebellar  Disease 
Cerebral    Haemorrhage     (x) 
Cerebro -spinal  Meningitis 
Chloroma 
Cinchonism 


Cirrhosis  of  Kidney  (x) 
Embolism  of  Brain 
Epilepsy 
Hydrocephalus 
Hysteria 
Lead-poisoning 
Lightning  stroke 
Locomotor  Ataxy 
Meningitis 
Migraine 
transitory 

Softening  of  Brain 
Suppression  of  Menses 
Syphilis 

Tobacco,  Abuse  of 
Tumour  of  Brain 
Uraemia 

Temporary  amaurosis  may 
be  caused  by  quinine  and 
salicine. 


564-565 


THE  NOSE 


187 


566.  THE  NOSE 

The  anterior  nares  are  examined  with  a  warmed  speculum 
illuminated  by  a  forehead-  or  electric  torch,  the  tip  of  the  nose 
being  raised  and  the  head  tilted  back.  The  superior  turbinated 
bone  is  almost  invisible.  The  middle  meatus  is  the  usual  seat 
of  polypus  and  of  pus  from  antrum,  frontal  sinus,  or  diseased 
ethmoid  ;  while  the  inferior  meatus  commonly  gives  lodgment 
to  foreign  bodies.  The  posterior  nares  are  examined  with  the 
larnygoscope,  the  smallest  mirror  being  employed  upside  down. 


567.  Red 

Acne  Rosacea 
*Alcoholism 
*  Amenorrhea  a 

Boil 
*Dyspepsia 

Erysipelas 

Rhinitis,  Chr.  Hypertrophic 

Rhinophyma 

(See  Erythema,  344) 

The  pressure  of  a  pince-nez 
is  responsible  for  some 
cases  and  insufficient 
clothing  for  others. 

568.  Butterfly  Nose 

A  red  patch  on  each  side  of 
the  bridge 

Lupus  Erythematosus 

569.  Nose  Swollen 
Cellulitis 
Erysipelas 
Injury 

Myx  oedema 

Rhinophyma 

Stings 


570.  Nose  Broadened 
Cretinism 

Mongolian  Imbecility 
Myxcedema 
Tumours 

Variola 

571.  Potato  Nose 
Rhinophyma 

572.  Saddle  Nose 

Chronic  Atrophic  Rhinitis 
Injuries 
*Syphilis 

573.  Bridgeless  or  Pug 

Achondroplasia 
Adenoids 

^Hereditary  Syphilis 
Imperfect  Development 
Injuries 

574.  Gangrenous  Tip  of  Nose 
Frost-bite 

Lupus 

Raynaud's  Disease 
Syphilis 

566-574 


188 


THE  NOSE 


575.  Distension  of  Transverse 
Nasal  Vein 

Adenoids  (Scanes-Spicer) 

576.  Sneezing 
Adenoids 
Asthma 

Chronic  Hypertrophic  Rhi- 
nitis 
*Coryza 

Ear,  Irritation  in 

Gout 
*Hay  Fever 

Hooping  Cough 


Hysteria 

Iodism 

Irritants 

Dried  Mucus 

Euphorbium 

Ipecacuanha 

Snuff 

Veratrum  album 
*Measles  (invasion) 
Polypus 
Spur  of  Septum 

It  may  be  produced  reflexly 
by  bright  light. 


575-576 


THE   NOSTRTLvS 


189 


577.  THE  NOSTRILS 


578.  Collapsed  Nostrils 
Adenoids 

Nasal  Obstruction  (580) 

579.  Dilating  with  Respiration 
This  occurs  chiefly  in  children. 

*Broncho-pneumonia 

Collapse 

Diphtheritic  Laryngitis 
*Dyspncea,  Acute 

Emphysema 

Hay  Fever 

Perforation  of  Palate 
*Pleurisy 

Pneumonia,  Acute 

Post -pharyngeal  Abscess 

Spasmodic  Asthma 

Tetanus  neonatorum 

%*  Mobile     nostrils     are     also 
found  in  neurotic  subjects. 


580.  Obstructed  Nostrils 

The  examination  of  a  child  is 
best  made  with  the  patient 
lying  on  his  back  and,  pre- 
ferably, while  asleep ;  the 
nostrils  being  compressed 
alternately. 

Abscess  of  Septum 
Adenoids 

Antrum,  Distended 
*Coryza,  I. 


Cyst,  Middle  Turbinated 
Deviation  of  Septum 
Diphtheria 
Eczema  Crusts 
Exostosis 
*Foreign  Body 
Glanders 
Gummata 
u  on  septum 

Haematoma  of  Septum 

Hay  Fever 

Hypertrophic    Rhinitis, 
Chronic 

Malignant  Disease 

Membranous  Rhinitis 

Osteoma 

Pharynx,  Growth  in 
*Polypus 

Post-pharyngeal  Abscess 

Rhinolith 

Rhinoscleroma 

Sinusitis 
*Spur  of  Septum 

Syphilis 
with  snuffles 

Tubercle 
*Turbinated  Bone,  Enlarged 

Typhus  (prodromal) 

Variola  (prodromal) 

581.  Large  Nostrils 
Atrophic  Rhinitis 


577-581 


190 


RH1NORRH0EA 


RHINORRHCEA 


582.  Watery  or  Mucous 
Arsenic -poisoning 
Bronchitis,  I. 
♦Coryza 
Foreign  Body 
Fracture  of  Base 

cerebro-spinal     fluid  ;     this 
does  not  stiffen  linen 

*Hay  Fever 
*Hooping  Cough 
invasion 
Influenza 
Iodism 
Irritants 
Lacrymation 
♦Measles 
Refractive  Errors 
Rhinolith 
Spasmodic  Asthma 

alternating   with    the    par- 
oxysms 

Trigeminal  Neuralgia 
Typhus,  i. 
Worms 

The  condition  may  also  be 
due  to  local  irritants,  such 
as  ammonia,  pepper, 
sulphurous  acid,  etc. 
See  next  section  (later 
stage) 


583.  Purulent   Discharge    or 
Ozsena 

Atrophic  Rhinitis,  Chr. 

very  offensive 
Cancer 

Caries  of  Ethmoid,  etc. 
Diphtheria,  Nasal 


Empyema  of  Antrum 
offensive — unilateral 
*Empyema  of  Frontal  Sinus 
*Foreign  Body 
Glanders 
Gonorrhoea 

Hypertrophic  Rhinitis,  Chr. 
offensive 

Lupus 

Membranous  Rhinitis 

Necrosis 

Rhinolith 

Sarcoma 

Scarlatina 

sequela 
♦Syphilis,  Tertiary 

offensive 
Syphilis,  Hereditary 

snuffles 
Tuberculous  Rhinitis 
Ulceration 

584.  Blue  Discharge 

Bacillus  pyocyaneus  in  Sinus 

585.  Nasal     Regurgitation     of 
Food 

Bulbar  Paralysis 

Cleft  Palate 

♦Diphtheritic  Paralysis 

Myasthenia  Gravis 

Perforation  of  Palate 

malignant,  syphilitic,  tuber- 
culous or  traumatic 

Post-operative  Paralysis 

♦Postpharyngeal  Abscess 

Pseudo-Bulbar  Paralysis 

582-585 


RHINORRHCEA 


191 


586.  Epistaxis  or  Bleeding 
Adenoids 
Ague 

Alcoholism 
Amenorrhcea 
Anaemia 
Angeioma 
Aortic  Insufficicnce 
Arsenicism 
*Arterio-sclerosis 
*Blows 
Bronchial  Glands,  Enlarged 
Bronchitis 
Caisson  Disease 
Carcinoma  of  Nose 
Caries,  Nasal 
Catarrh,  Chronic  Nasal 
Cerebral  Congestion 
Chloroma 
Chlorosis 
♦Cirrhosis  of  Kidney 
„         of  Liver 
Dengue 
Diphtheria 
Dysentery 
Emphysema 
*Enteric  Fever 
Erysipelas 
Fibroma  of  Nose 
Foreign  Body 
Fracture  of  Base 
Goitre 
Haemophilia 
Hooping  Cough 
Hyperaemia  of  Brain 
Hypertrophy  of  Heart 
Infantile  Scurvy 
Influenza 
Jaundice 


Leukaemia 
Measles 
Menopause 

Menstruation,  Vicarious 
Mitral  Stenosis 
Myxcedema 
Nephritis,  Chronic 
Ovarian  Disease 
Peritonitis 
Pernicious  Anaemia 
Phosphorus  -poisoning 
Pleurisy 
*Polypus 
Psittacosis 

Purpura  Haemorrhagica 
Pyaemia 

Relapsing  Fever 
Remittent  Fever 
Salicism 

Sarcoma  of  Nose 
Scarlatina 
Scurvy 

Telangiectasis 
Thrombosis,  Cerebral 
Thymus,  Enlarged 
Tuberculosis 
Tumours  of  Neck 
Ulcer  of  Nose 

leprous,  malignant,  syphi- 
litic  or  tuberculous 

Varicosities 
*Worms 
Yellow  Atrophy,  Acute 

Epistaxis  occurs  in  health 
in  connection  with  violent 
nose-blowing  or  sneezing, 
diving,  mountaineering, 
aviation,  and  sudden 
changes    of   temperature. 


586 


192 


THE  SENSE  OF  SMELL 


587.  THE  SENSE  OF  SMELL 


In  testing  for  smell,  ascertain  first  that  the  mucous  membrane 
is  duly  moist.  Then  make  the  patient  smell  valerian,  essence  of 
violets,  and  oil  of  cloves,  and  distinguish  between  them.  Irritating 
vapours  like  ammonia  act  upon  the  trigeminal  nerve  and  should  be 
avoided.  The  centre  for  smell  is  in  the  tip  of  the  uncinate  gyrus, 
the  nerve  fibres  being  distributed  to  the  Schneiderian  membrane 
over  the  upper  part  of  the  nasal  fossse. 


588.  Lost  or  Impaired  (Anos- 
mia) 

It  may  be  lost,  on  one  side 
only,  in  connection  with 
hemianesthesia  (hemian- 
osmia)  and  is  then  usually 
functional.  A  common 
cause  is  obstructed  or  dry 
nostrils. 

Abscess  at  Root  of  Nose 
*Adenoids 
Aphasia 

sometimes  unilateral 

Cerebellar  Tumour 

Congenital  Absence  of  Olfac- 
tory Bulbs 
*Coryza 

Embolism 

Facial  Paralysis  (x) 

General  Paralysis 
25  per  cent. 

Haemorrhage,  Cerebral 

Hydrocephalus 

Hysteria 

Influenza,  Sequel  of 
*In  juries  to  Head 

Locomotor  Ataxy  (x) 

Noxious  Vapour 
*Occlusion  of  Nostrils 

Olfactory  Clefts 

Neuritis 


Ozaena 

Paralysis  of  Fifth  Nerve 

from  dryness  of  mucous 
membrane 

Polypi 

Rhinitis,  Atrophic 

,,        Hypertrophic 
Rhinolith 
Septal  Spur 
Septum,  Deviation  of 
Syphilis 
Thrombosis 
Tobacco;  Abuse  of 
Tumour  of  Brain 

post,  third  of  internal  cap- 
sule or  in  uncinate  con- 
volution 

Typhus 

589.  Hyperosmia 

Extreme  sensitiveness  to 
existent  smells. 

Neurasthenia 
It  is  usually  an  idiosyncracy. 

590.  Subjective    Smells 
(Parosmia) 

A  pleasant  odour  may  be 
pronounced  disagreeable, 
and  vice  versa. 


Aura  epileptica 


587-590 


THE  SENSE  OF  SMELL 


193 


Subjective    Smells    (Paros- 
mia ) — continued 
Empyema  of  Antrum 
Haemorrhage,  Ethmoidal 
*Hysteria 
♦Influenza 
Insanity 


Myxoedema 
Meningeal  Thickening 
Meningitis 
Neurasthenia 
Sinusitis,  Frontal 

„  Sphenoidal 

Tumour  of  Brain 


590 


194 


THE  MOUTH 


THE  MOUTH 

591. — The  first  act  of  digestion  takes  place  in  the  mouth, 
where  the  ptyalin  of  the  saliva,  by  converting  starch  into  glucose, 
renders  it  soluble.  The  quantity  of  saliva  secreted  daily  is 
from  two  to  three  pints  ;  its  alkalinity  is  due  to  sodium  phos- 
phate, not  to  the  carbonates. 


592.  Dribbling,    Salivation    or 

Ptyalism 

It  is  generally  due  to  reflex 
irritation  in  the  aliment- 
ary canal.  When  associ- 
ated with  dysphagia  or 
paralysis,  the  quantity 
may  be  only  apparently 
excessive. 

Adenoids 

Ague 

Angina  Ludovici 

Aphtha? 

Arterio-sclerosis 

Bulbar  Paralysis 

Calculus,  Salivary 

Cancer  of  Larynx 
of  Stomach 

Cancrum  Oris 
*Dementia 

Dental  Abscess 
*Dentition 

Dilatation  of  Stomach 

Diphtheritic  Paralysis 

Epulis 
*Facial  Paralysis 
*Foreign  Body  in  Mouth 

Gastric  Irritation 

Glossitis 

Haemophilia 

Hydrophobia 

Hypoglossal  Paralysis 

Hysteria 

Idiocy 


Jaw,  Dislocation  of 

„  Fractured 
Liver  Disorders 
Mental  Emotion 
Mumps 

saliva  thickened 

Myasthenia  Gravis 
Myelo-sarcoma 
Necrosis  of  Jaw 
Neuralgia  of  Fifth  Nerve 
Overaction  of — 

Aconite 

Antimony 

Arsenic 

Bromides 

Cantharides 

Chlorate  of  Potash 

Copper 

Iodine 

Mercury 

Phosphorus 

Pilocarpine 
Pancreatic  Disease 
Paralysis  Agitans 
Pellagra 

Pernicious  Anaemia 
PregnancjT 

Pseudo-  bulbar  Paralysis 
Pyorrhoea  Alveolaris 
Ptyalorrhcea 
*Quinsy 
Ranula 

591-592 


THE  MOUTH 


195 


Dribbling;     Salivation     or 
Ptyalism — continued 
Scurvy 
Sprue 
*  Stomatitis 
of  all  kinds 

Syphilis 

Teeth,  Jagged 

Typhus 

Ulcer  of  Duodenum 

„      of  Mouth 

,,      of  Stomach 
Variola 

Vincent's  Angina 
Worms 

***  In  uraemia  the  saliva  con- 
tains urea. 

593.  Saliva  Diminished 

Belladonna-poisoning 

Cholera 
*Diabetes 

Facial  Paralysis 
*Fevers 

Xasal  Obstruction  (580) 
apparent  only 

594.  Acid  Saliva 

Carcinoma 
Diabetes 
Leukaemia 
Pernicious  Anaemia 

595.  Foam  at  Mouth 

Apoplexy  (late) 
*Epileptic  Seizure 
Hystero-epilepsy 
Malingering 

soap 
Pulmonary  Affections  with 
Prostration 


596.  Blood  from  Mouth 

Adenoids 

Bleeding  Gums  (620) 

Epilepsy 

bitten  tongue 
Ulcers  of  Fauces 
,,      of  Mouth 
Varicose  Veins 
in  the  pharynx. 
Apparent   causes    are   epis- 
taxis,   hsematemesis,  and 
haemoptysis. 

597.  Attempts  to  Bite 

Hydrophobia  (early) 
Lyssaphobia  (late) 

598.  Dry 
Diabetes 
Gastritis,  Chr. 
Xasal  Obstruction 
Xephritis,  Chr. 
Pyrexia  (295) 
Xerostoma 

(See  580) 

Cold    Breath    (See    Subnormal 
Temperature,  292) 

599.  Mouth  Open 

This     is     the     commonest 
cause  of  a  dry  mouth. 

*Adenoids 

Asthma 

Bulbar  Paralysis 

Cancrum  Oris 

Cretinism 

Dislocated  Jaw 

Dyspnoea,  Acute 

General  Paralysis 

Glossitis 
*Idiocy 

Idiopathic    Muscular    Atro- 
phy 
2  592-599 


196 


THE  MOUTH 


Mouth  OrEN — continued 
Landouzy  -  Dejerinc   Para- 
lysis 
♦Obstructed  Nostrils  (589) 
Post-pharyngeal  Abscess 
Prostration  (234) 
Quinsy 
Stomatitis 
Tonsillitis 

Orthopncea  causes  the  jaw 
to  drop  by  gravitation 
and  therefore  the  mouth 
to    open    (1224). 

Mouth  Shut 

(See  Trismus,  1424) 

600.  Mouth     Drawn     to     One 
Side 

♦Facial  Paralysis 

to  ojmosite  side  (unless 
dating  from  childhood) 

Facial  Hemiatrophy 

, ,     Hemihypertrophy 

♦Hemiplegia 

Scars 

♦*♦  Unilateral  loss  of  teeth  may 
mislead. 

601.  Swellings 

Actinomycosis 
Dermoid  Cyst 
Epithelioma 


Hydatids  (x) 
Lipoma 
Naevus 
♦Ranula 

Tuberculous  Glands 
(See  Gums,  620) 

602.  Oral  Illumination 

An  electric  torch  should 
be  inserted  into  the 
mouth  in  a  darkened 
room.  If  the  antrum 
appears  dark — 

Empyema  of  Antrum 
Growth  in  Antrum 


603.  Davidsohn's  Sign 

On  placing  an  electric  torch 
in  the  mouth,  there  is  less 
illumination  of  the  pupil 
on  the  side  of  the  lesion 
(see  560). 

Empyema  of  Antrum 
Tumour  of  Antrum 


604.  Yawning 

A  yawn  is  commonly  due 
to  fatigue  or  to  deficient 
oxygenation  of  the  blood. 
If  persistent,  there  may 
be  irritation  of  Arnold's 
nerve  as  by — 

Wax  in  Meatus 


599-604 


THE  LIPS 


197 


605.  THE  LIPS 


Pallid  (see  Ancrmia,  385) 
Livid  (sec  Cyanosis,  396) 

606.  Swollen  Lips 
Abscess,  Alveolar 

*Abscess,  Labial 

Acromegaly 

Adenoids 

Angeioneurotic  (Edema 
*Bites 

Cancrum  Oris 

Chancre 

Cheilitis,  Glandular 
Miliary 

Corrosive -poisoning 

Cretinism 

Elephantiasis  of  Lips 

Epilepsy 

Jagged  Teeth 

Lymphangitis,  Chronic 
'  blubber  lips ' 

Macrochilia,  Congenital 

Myxcedema 

Stings 

Stomatitis 

Tuberculosis 

Ulcer 

Worms 

607.  Local  Swelling 

Chancre 
Cysts 
*Epithelioma 
Nsevus 


Plaque  Muqueuse 
Perleche 
angles 

608.  Tapir  Lip 

The  projection  of  the  lip 
resembles  that  of  this 
animal. 


Landouzy-Dejerine 
lysis 


Para- 


609.  Herpes  Labialis 

Ague  (hot  stage) 

Appendicitis 

Cerebro- spinal  Meningitis 
*Coryza,  Simple 
v  Foot-and-Mouth  Disease 

Irritation  of  Fifth  Nerve 

Malaria 
*Pneumonia,  Acute 

Remittent  Fever 

610.  Ulcerated  Lips 

Anthrax  (x) 
Cancrum  Oris 
Carbuncle 
Chancre 
Condyloma 
Epithelioma 
Soft  Sore 
Stomatitis 

Sordes  (see  Gums,  624) 

611.  Fissures  at  Angles 
Hereditary  Syphilis 


605-611 


198 


THE  BUCCAL  MEMBRANE 


612.  THE   BUCCAL    MEMBRANE 


613.  Ulcers 

Aphthae 
Bites 
Cancer 
*Cancrum  Oris 
Corrosive-poisoning 
Glanders 
Gumma 
Sprue 

Stomatitis,  Ulcerative 
Vesicles,  Broken 

A  common  cause  is  a  jagged 
tooth. 

614.  Papules 

Lichen  Planus 
Miliary  Cheilitis 
Stomatitis 

615.  Vesicles 
Herpes 

Stomatitis,  Aphthous 

Varicella 

Variola 

616.  Peteehise 

Anaemia  Gravis 

Haemophilia 

Purpura 

Scurvy 

Trauma 

Ulcerative  Endocarditis 


617.  Pigment  Patches 

*Addison's  Disease 
Argyria 
Cancer  (x) 
Cholangitis 
Cirrhosis  of  Liver  (x) 
Lead-poisoning 

Gabler's  or  Oliver's  spots. 
Pernicious  Anaemia 
Ulcer  of  Stomach  (x) 

Found  in  Lascars,  some 
negro  tribes,  and,  rarely, 
in  healthy  Europeans. 

618.  Koplik's  Spots 

Bright  red  spots,  the  size  of 
a  pin's  head,  each  with  a 
bluish-white  speck  in  the 
centre  ;  found  also  inside 
the  lips,  but  never  on  the 
gums.  The  somewhat 
similar  spots  of  aphthous 
stomatitis  have  yellow 
centres. 

Measles 

They  appear  two  days  before 
the  eruption  and  last  for 
four  days. 

619.  Red  Swelling  over  Sten- 
son's  Duct 

Mumps,  i. 
Tresilian's  Sign 


612-619 


THE  GUMS 


199 


THE  GUMS 


620.  Spongy  and  Bleeding 
Actinomycosis 
Alveolar  Abscess 
Anaemia,  Aplastic 
„  Pernicious 

„  Splenic 

Cachexia 
Cancrum  Oris 
Carious  Teeth 
Dentition 
Diabetes 
Dyspepsia 
Erythema  Bullosum 
Gastric  Irritation 
Gingivitis,  Tuberculous 
Haemophilia 
Infantile  Scurvy 
Leukaemia 
Lymphadenoma 
Overaction  of — 
Arsenic 
Bismuth 
Iodides 
Lead 
Mercury 
Phosphorus 
Phthisis 
Purpura 

Pyorrhoea  Alveolaris 
Scurvy 
♦Stomatitis  in  general 
Syphilis 
Tartar 
Trauma 

Ill-fitting  dentures  or  broken 
teeth  may  be  responsible. 


621.  Pale  Gums 

♦Anaemia  (385) 
Haemorrhage 

622.  Coloured  Line 

At  the  junction  of  the  teeth 
with  the  gum ;  most 
marked  in  the  lower  jaw. 

Bismuth 
bluish-black 

Copper-poisoning 

green 
♦Lead-poisoning 

blue  (Burton's  Line) 
Mercurialism 

bluish 
Pyorrhoea  Alveolaris 

red 
Scurvy 

purple 
Spongy  Gums 

red 
Zinc 

bluish 
*+*  Nearly  all  workers  in  lead 
show  a  blue  line,  whether 
they  suffer  from  plumbism 
or  not. 

623.  Circumscribed  Swelling 

Actinomycosis 
♦Alveolar  Abscess 

Cyst,  Dental 
♦Epulis 

Epithelioma 

620-623 


200 


THE  GUMS 


Circumscribed     Swelling — 
continued 
Myelosarcoma 
Papilloma 
Periodontitis 

624.  Sordes 

A  brownish  deposit  between 
the  teeth  and  the  gums  as 
well  as  on  the  lips. 

*Acute  Yellow  Atrophy 

Pneumonia 

Prostration  (234) 
*Typhic  State  (62) 


625.  Swollen  Jaw 

*Abscess 
Acromegaly 
Actinomycosis 
Antrum,  Empyema  of 

„         Growth  in 
Cancer 
Cysts 
Necrosis 
Odontoma 
Osteoma 
Periostitis 

Phosphorus-poisoning 
Sarcoma 
Syphilis 
Tubercle 


623-625 


THE  TEETH 


201 


THE  TEETH 


626.  Grinding  Teeth 
Ancemia  of  Brain 
Anterior  Poliomyelitis 
Chorea 

Epilepsy 

Gout 

Hydrocephalus 

Hyperemia  of  Brain 
*Intestinal  Irritation 

Rheumatism 
*Tuberculous  Meningitis 
intense 

Tumour  of  Brain 
Variola 
*Worms 

627.  Carious  Teeth 

Due    chiefly  to    Leptothrix 
buccalis. 

Diabetes 

Eructations,  Acid 
Exophthalmic   Goitre 
Injuries 

Naso-pharyngeal     Obstruc- 
tion (580) 
Pernicious  Anaemia 
Phosphorus-poisoning 

628.  Teeth  Loose 

Abscess,  Alveolar 
Cancrum  Oris 
Dentition,  Second 
Diabetes 
Leukaemia 
*Mercurialism 


Phosphorus-poisoning 

Purpura 
*Pyorrhcea  Alveolaris 
♦Recession  of  Gums 

Scurvy 

Stomatitis 

Wasting    Diseases,    Acute 
(311) 

Xerostoma 

629.  Teeth    Laminated     (per- 
manent  set) 

Due  to  intervals  of  arrested 
nutrition. 

History  of  Acute  Disease  in 
Childhood 
(See  Nails,  907) 

630.  Dentated 

Malnutrition 

Struma,  History  of 

while   the   teeth   were   un- 
opposed 

631.  Notched  and  Conical 

Upper     central   permanent 
incisors. 


Hereditary  Syphilis 

'  Hutchinson's  '    or 
driver  teeth ' 


screw  - 


632.  Moon's  Teeth 

The  first  molars  are  small 
and  domed. 

Syphilis 


626-632 


202 


DENTITION 


633.  DENTITION 

The  table  gives  the  number  of  teeth  at  the  following  ages  : — 


Temporal 
Months. 

7 

7 

Teeth. 
4 
..       8 
..     12 
..     16 
..     20 

Years. 

6£ 

7 

8 

9 
10 

11-12 
12-15 
17-24 

Permanent 

Teeth. 
4 

7  to  10 

8 

12  to  14 

. .     12 

14  to  20 

..     16 

18  to  36 

. .     20 

..     24 

..     28 

..     32 

The  first  teeth  of  the  second  dentition  to  appear  are  not  the 
incisors,  but  the  first  molars  of  the  upper  jaw. 


634.  Early  Dentition 

Hereditary  Syphilis 
Tuberculous  Diathesis 


635.  Late  Dentition 

Cretinism 
Idiocy 
Malnutrition 
Mongolian  Imbecility 
*Rickets 

in  irregular  order 


633-635 


THE   PALATE 


203 


THE  PALATE  OR  ROOF  OF  THE  MOUTH 


636.  White 
Aphthae 

Callosities 

Diphtheria 

Necrosis 

637.  Ulcerated 
(See  613) 

Ulcers  may  be  due  in  infants 
to  a  foul  teat  or  a  horny 
nipple. 

638.  Swollen 

*Abscess 

Adenoma 

Cancer 
*  Cysts 

Epithelioma 

Fracture 

Gumma 

Infantile  Scurvy 

Lupus 


Meningocele 

Naevus 

Tubercle 


639.  Perforated 

Cancer 
Cleft  Palate 
Injury 
Measles 
*Syphilis 
Tuberculosis 
Variola 

Jaw    Closed    (see    Trismus, 
1424) 

640.  Forchheimer's  S  gn 

A  red  maculo -papular  erup- 
tion on  soft  palate. 


Rotheln 


636-640 


204 


THE  TONGUE 


THE  TONGUE 

641. — '  L'ooil  est  lc  miroir  de  l'ame,  ot  la  languo  le  miroir 
de  l'estomac,'  as  Henri  Roger  used  to  say  at  his  c Unique.  The 
aphorism  may  not  have  been  original,  but  it  is  quite  true,  though 
there  are  fallacies  in  both  cases,  and  the  bowel  must  be  included. 
Fur  consists  largely  of  broken  down  epithelial  scales,  which, 
normally,  are  removed  by  friction  with  solid  food.  When  none 
is  taken,  as  in  fevers,  the  scales  remain  and  form  the  '  fur.' 


642.  Dry  and  Glazed  Tongue 

Dysentery,  Acute 

Enteritis,  Acute 

Gastritis,  Erythematous 

Intestinal  Obstruction 
*Nasal  Obstruction 

Peritonitis,  Ac. 

Phthisis,  in. 

Septicaemia 
*Typhic  State  (62) 

Wasting  Diseases  (311) 
*Xerostoma 

43.  Dry  and  Furred 
Ague 

Continued  Fevers 

Dyspepsia 

Erysipelas 
*Exanthemata 

Hyperpyrexia 

Infective  Endocarditis 
*Jaundice 

Lead-poisoning 
*  Nasal  Obstruction  (580) 

Peritonitis 

Pneumonia 
*Pysemia 

Remittent  Fever 

Tuberculosis,  Acute 

Typhic  State  (62) 
'  baked  tongue ' 

Typhus 


644.  Moist  with  White  Fur 

Alcoholism 

Apoplexy 

*Catarrh  of  Bile-ducts 
of  Mouth 

Colitis 

Constipation 

Cyanotic  Liver 

Delirium  Tremens 

Duodenal  Catarrh 

Enteric  Fever,  i. 
centre  only 

Erysipelas 
*Fsecal  Accumulation 
*Gastric  Irritation 

Gastritis,  Acute 
,,  Chronic 

Gout 

Hepatic  Abscess 

Hepatitis,  Acute 

Lithsemia 

Measles 
centre  only 

Meningitis,  Simple 

Migraine 

Nasal  Obstruction  (5 SO) 

Phthisis 

Pneumonia,  Acute 

Pyrexia  (295) 
*Quinsy  k*j 

Relapsing  Fever 

641-644 


THE  TONGUE 


205 


Moist    with    White    Fur — 

continued 
Remittent  Fever 
Rheumatism 
Scarlatina,  i. 

centre  only 
♦Tonsillitis 
Tuberculosis,  Acute 

centre  only 

Typhus 

***  Malingerers  use  chalk  ;  this 
froths  up  on  adding  an 
acid. 

645.  Brown  Fur 

Due  to  an  admixture  of 
blood  or  hsematin  with 
broken  down  epithelium. 

♦Enteric  Fever 

3rd  week 

♦Erysipelas,  Severe 

Gastritis,  Chronic  (x) 

Gout  (x) 

Jaundice  (392) 

Remittent  Fever 

Scurvy 

Septicaemia 

Strangulated  Hernia 

Tuberculosis,  Acute,  n. 

Typhic  State  (62) 
♦Typhus 

♦*♦  Beware    of    brown    stains, 
e.g.       from      liquorice      or 
chocolate. 

646.  Unilateral  Furring 

Generally  due  to  inability 
to  bite  with  one  half  of 
the    jaw. 

Abscess,  Dental 

Periodontitis 

Pulpitis 


Tooth-Cutting 
Toothlessness,  Unilateral 
Trigeminal  Neuralgia 

647.  Large,  Pale,  and  Indented 

This  is  the  anaemic  type  of 
tongue. 

Acromegaly 
♦Anaemia   (385) 
Aphthae 

fungoid  growth 

♦Atony  of  Stomach 
Cancer  of  Stomach 
Gastritis,  Chronic 
in  weakly  people 

♦Neurasthenia 

OEdema 

Relapsing  Fever 
♦Salivation 

Ulcer  of  Stomach 

648.  Swollen  or  Protruding 

Achondroplasia 

Acromegaly 

Actinomycosis 
♦Anaemia 

Aneurysm  of  Aorta 

Angina  Ludovici 

Calculus,  Salivary 

Carcinoma 

Cretinism 

Cyanosis 
♦Glossitis 

Idiocy 

Insanity 

Irritant  Poisons 

Macroglossia,  Congenital 
„  Fibromatosa 

Mitral  Disease 

Mongolian  Imbecility 

Myxoedema 

645-648 


206 


THE  TONGUE 


Swollen    or    Protruding — 
continued 
(Edema 
Pemphigus 
Ranula,  Inflamed 
Scurvy 

Shell-tish  poisoning 
Urticaria 
Variola 

649.  '  Strawberry  Tongue  ' 
Ichthyosis  Linguae 
Pneumonia  (x) 

*Scarlatina 

650.  '  Raw-Beef  Tongue  ' 

Diabetes 

651.  Plaques  or  Psoriasis 

Syphilis 

The  primary  sore  is  also 
met  with. 

652.  Hairy  Tongue 

Significance  unknown ; 

sometimes   nsevoid. 

653.  Black 

Bismuth 

Charcoal 

Iron 

Nigrities 

***  Mouth- washes  of  hydrogen 
peroxide  will  blacken  the 
tongue. 

654.  Pigment  Patches 

Glossitis,  Old 

Those  that  are  found  on 
the  buccal  membrane 
may  occur,  though  more 
rarely,  on  the  tongue 
(see  617). 


655.  Small 

1  Atrophy,  Smooth  ' 
syphilitic  or  tuberculous 

Bulbar  Paralysis 

Enteric  Fever 

Gastritis,  Chronic 
*Haemorrhage 
*Paralysis  of  Hypoglossals 

Peritonitis,  Acute 

Pseudo-hypertrophic    Para- 
lysis 

Typhic  State  (62) 

656.  Fissured 

Cirrhosis  of  Liver 
*Diabetes 

Dysentery,  Chronic 

Erysipelas,  Severe 
♦Glossitis,  Old 

Mongolian  Imbecility 

Scars  of  Ulcers 

*  Syphilis 

%*  Sometimes   normal,    especi- 
ally in  old  people. 

657.  Ulcerated 

*  Aphthae 
Chancre 
Dyspepsia 

on  tip 
Epithelioma 

on  side,  hard 
Foot-and-Mouth  Disease 
Gastritis  (x) 
Herpes 
Hooping  Cough 

'  fraenal  ulcer  ' 

*Jagged  Tooth 
Pemphigus 
Precancer 

648-657 


THE  TONGUE 


207 


Ulcerated — continued 
Sprue 
under-surfaco 

Stomatitis 
♦Syphilis,    Secondary    and 
Tertiary 
broken  down  gumma,  etc. 

Tubercle 
Tuberculosis 

side  or  tip,  not  hard 

Ill-fitting  dentures  will  pro- 
duce ulceration. 

658.  Bitten  or  Scarred 

Bulbar  Paralysis 
*Epilepsy 
*Fall 

Hystero-epilepsy 

Syphilis 

659.  Nodules  on  Tongue 

Actinomycosis 
Concretions  (?) 
*Gumma 
Lymphangeioma 
Tubercle 

660.  Tumours  of  Tongue 
Actinomycosis 
Angeioma 

Cancer 

*Cysts 
♦Epithelioma 

Fibroma 

Lingual  Thyroid 
„       Tonsil 

Lipoma 

Macroglossia  Fibromatosis 

Papilloma 

Sarcoma 


661.  Trembling 

♦Alcoholism 

Bromism 

Bulbar  Paralysis 
'  like  a  bag  of  worms  ' 

Chorea 
jerking 
♦Dslirium  Tremens 

Enteric  Fever 

Epilepsy 

Friedreich's  Disease 
jerking 

General  Paralysis 

Neurasthenia 

Paralysis  Agitans 

Sclerosis,  Disseminated 
♦Tobacco,  Abuse  of 
♦Typhic  State  (62) 

662.  Unilateral  Protrusion 

Aneurysm,  Basilar 
♦Apoplexy 

Caries    of    Upper    Cervical 
Vertebrae,  Partial 

Cerebral  Embolism 
♦Facial  Paralysis,  Central  (x) 

Hemiplegia  (1335) 

Paralysis     of     One     Hypo- 
glossal 

Syringomyelia 

Tumour  of  Brain  or  of  upper 
part  of  Cord 

663.  Inability  to  Protrude 

Basal  Meningitis 
Bulbar  Paralysis 
Caries  of  Atlas  or  Occiput 
♦Diphtheritic  Paralysis 
General  Paralysis 
Lesion  of  both  Hypoglossal 
Nuclei 

657-663 


208 


THE  TONGUE 


Instability  to  Protrude — con- 
tinued 
Lead-poisening 
Locomotor  Ataxy  (x) 
Tumour  of  Base 

of  Cervical  Cord 


664.  Aphthongia 

A  spasm  of  the  tongue  set 
up  by  the  attempt  to 
speak. 

Thomsen's  Disease 

A  functional  form  occurs 
in  stammerers. 


665.  Geographical  Tongue 

With  map -like  markings. 
Glossitis,  Chr.  Superficial 
Hyperchlorhydria 
Rickets 


666.  Smoker's  Patch 

Small  and  oval  with  yellow 
crust. 


667.  Leukoplakia 

A  smooth,  horny,  blue  and 
white  patch. 

Gout 

Rheumatism 

Smoking,  Excessive 

It  is  liable  to  develop  into 
epithelioma. 

668.  Sclerosing  Glossitis 

Syphilis 

669.  Folio-Papillitis 

The  foliate  papillae  are  red, 
swollen,  and  acutely 
painful. 

Gout 
Rheumatism 

670.  Yellow  Patches 

Addison's  Disease 
Glossitis,  Old 
Xanthelasma 

671.  Annular  Patches 

Eczema 


663-671 


THE  TASTE 


209 


672.  THE  TASTE 

The  four  primary  divisions  of  Taste  are  : — bitter,  sweet, 
acid,  salt.  The  principal  nerve  of  taste  is  the  glosso-pharyngeal, 
which  is  distributed  over  the  posterior  third  of  the  tongue  ;  but 
the  fifth  nerve,  which  supplies  the  anterior  two-thirds,  and  the 
chorda  tyrupani,  include  some  gustatory  fibres.  The  Taste 
Centre  is  probably  the  tip  of  the  temporo-sphenoidal  lobe. 
To  test  the  sense,  the  patient  should  be  required  to  distinguish 
between  salt,  sugar,  quinine,  and  citric  acid — all  in  powder 
form.  Both  the  front  and  the  back  of  the  tongue  should  be 
tested.  Taste  is  a  faculty  which  is  soon  exhausted,  so  that 
repetitions  must  be  few. 


673.  Lost     or     Impaired 
(Ageusia) 

Ageusia    may    be     central, 
peripheral,  or  conductive. 

Adenoids 
*Anaesthesia   or  Paralysis  of 
Fifth  Nerve 

Bulbar  Paralysis 

Bromism 
*Coryza 

Facial  Paralysis 

when    chorda    tympani     is 
involved 

Hay  Fever 

Hysteria 

Iodism 
*Xasal  Polypus  or  Obstruc- 
tion 

Paralysis  of  Glosso-pharyn- 
geal 

Rhinitis,  Atrophic 

„        Hypertrophic 

Stomatitis 

Tumour  of  Brain 


***  A  dry,  or  thickly  furred- 
tongue  necessarily  inter- 
feres with  taste.  In  some 
paralyses,  there  is  hemi- 
geusia,  or  loss  of  taste,  in 
one-half  of  the  tongue. 

674.  Perverted  (Parageusia) 
Aura  epileptica 

*Hysteria 

*Insanity  (see  Pica,  70) 
Pregnancy 

675.  Foul  (Cacogeusia) 
Action  of — 

Arsenic 

Copper 

Iodides 

Lead 

Mercury 

Tartar  Emetic 
Duodenal  Catarrh 
Duodenal  Ulcer 

bitter 
Dyspepsia 
Epilepsy 

672-675 


210 


THE  TASTE 


Foul  (Cacogettsia) — continued 
*Fsecal  Accumulation 
*  Gangrene  of  Lung 

Gastric  Irritation 

Hysteria 

Insanity 

Jaundice  (392) 

Lithsemia 

Liver  Affections 

Myx  oedema 


Pancreatic  Disease 
Peritonitis 
Phthisis 

Pyorrhoea  Alveolaris 
sweet  and  sticky 

Stomach,  Dilated 
*Teeth,  Caries  of 
Tonsillitis 
Typhus 
Variola 


675 


THE   FAUCES 


211 


676.  THE  FAUCES   OR  THROAT 

For  examining  the  throat,  an  electric  torch  is  tho  most 
convenient  instrument,  but  it  must  not  be  inserted  too  far 
back.  The  patient  should  say  '  Ah  '  when  the  posterior  wall 
is  inspected.  A  cautious  preliminary  swabbing  with  cocaine 
is  advantageous,  especially  when  digital  examination  is 
attempted.  In  the  case  of  children,  a  cork  should  be  used 
between  the  molar  teeth  to  prevent  the  finger  from  being 
bitten. 


677.  Reddened 

Belladonna-poisoning 
Coryza 

Diphtheria,  I. 
Erysipelas 
*Gastritis 
Gout 
Influenza 
Iodism 

Irritant-poisoning 
Malta  Fever 
*Measles 

Mediastinal  Abscess 
Pharyngitis,  Acute 
, ,  Chronic 

rough 
Quinsy 

Relapsing  Fever 
Roseola 
Rotheln 
*Scarlatina 

dark  red 

Tetanus 
*Tonsillitis 

678.  Swollen 

Amyloid 

Calculus,  Tonsillary 

Dengue 


Erysipelas 
*Hypertrophied  Tonsils 
*Measles 
Mumps 

Pharyngitis,  Acute 
*Pharyngitis,  Follicular 
Quinsy 
Scarlatina 
Tonsillitis,  Simple 
„  Lacunar 

,,  Rheumatic 

,,  Septic 

Variola 

679.  White  or  Grey  Patches 

A  membrane  is  not 
necessarily  due  to  the 
Klebs  -  Loffler  bacillus  ; 
the  streptococcus  pyo- 
genes may  be  the  cause. 

Carbolic  Acid  poisoning 
*Diphtheria 

a  fixed  and  spreading  mem- 
brane 

Follicular  Pharyngitis 
detachable 

Gangrenous  Sore  Throat,  i. 
Hydrochloric   Acid    poison- 
ing 

p  2  676-679 


212 


THE  FAUCES 


White  or  Grey  Patches — 
continued 
Measles  (x) 

very  rarely  membranous 
Pertussis  (x) 
Pharyngomycosis 

small     recurring     fibrous 
excrescences 

Scarlatina 

sometimes  membranous 
Septic  Tonsillitis 

membranous 
Vincent's  Angina 

membranous 

Inhaled  steam  may  produce 
a  membrane ;  and  mucus, 
cream,  or  a  tonsillary 
calculus  may  deceive. 


680.  Ulceration  of  Tonsils 
Cancer 
*Diphtheria 

after  separation  of  mem- 
brane 

Gangrene 
Glanders 

bluish 
Herpes  Eaucium 

sequel 

Influenza  (x) 
Scarlatina  (x) 
Syphilis 

chancre  or  plaques 

*Septic  Tonsillitis 

after  separation  of  sloughs 

Tonsillitis 

Tuberculous  Pharyngitis 

Vincent's  Angina,  n. 

flat,  with  hard  base  and 
sloping  edges.  Only  one 
tonsil  iisuallv  affected 


679-680 


THE  PHARYNX 


213 


THE  PHARYNX  OR  BACK  OF  THROAT 


681.  Bulging  of  Pharynx 
Adenoids 

Cancer 

Caries  of  Cervical  Vertebrae 
Epithelioma 
Glands,  Enlarged 
Gumma 
(Edema,  Acute 
from  stings,  etc. 

*Post-pharyngeal  Abscess 
Tumours 

682.  Vesicles  on  Pharynx 
*Herpes,  Pharyngeal 

Varicella 
Variola 

683.  Ulcers  of  Pharynx 

Cancer 
Chancre 
Condyloma 
Enteric  Fever  (x) 
Gumma 
Herpes 
Lupus  (x) 
Syphilis 

'  snail-track  ulcer ' 

Tuberculosis 
Variola  (x) 


684.  Growths,  Pharyngeal 
Adenoma 
Angeioma 

Cancer 

Epithelioma 

Gumma 

Papilloma 

Sarcoma 

685.  Mucous  Accumulation 

Alcoholism 

Glanders 

Lithsemia 
*Naso-pharyngeal  Catarrh 

Pharyngitis,  Chronic 
with  stellate  veins 

Pharyngitis,  Acute,  n. 
„  Follicular 

„  Granular 

Relapsing  Fever 

Scarlatina 


686.  Deviating  Uvula 

Often  normal. 


♦Facial  Paralysis 
Relaxed  Uvula 
Syphilis 
fixed 


681-686 


214 


THE   (ESOPHAGUS 


687.  THE   (ESOPHAGUS 

This  enters  the  stomach  on  a  level  with  the  body  of  the  tenth 
dorsal  vertebra.  The  left  bronchus  crosses  it  about  three  inches 
down. 


688.  Stenosis     of     (Esophagus 

Extrinsic — 

Aneurysm 

Cancer 

Caries  of  Spine 

Glands,  Enlarged 

Growth,  Mediastinal 

Thyroid,  Enlarged 
Intrinsic — 

Abscess,  Post-pharyngeal 

Cancer 

Congenital  Stenosis 

Foreign  Body 

Poisons,  Corrosive 

Spasm 

Stricture,  Cicatricial 
(See  Dysphagia,  693) 


689.  The  (Esophagoscope 

This  is  sometimes  of  assist- 
ance in  the  diagnosis  of 
pressure- dysphagia  such 
as  that  from  : — 

Aneurysm,  Thoracic 
Bronchial  Gland,  Enlarged 


Cancer 
Stricture 
Thyroid,  Enlarged 

690.  The  Gastroscope 

Used  with  a  general  anaes- 
thetic, this  has  demon- 
strated successfully  : — 

Cancer  of  Pylorus 
Gastric  Ulcer 
Petechias  on  Stomach 

691.  Gastro-Diaphany 

An  electric  glow -light  at 
the  end  of  a  stomach 
tube  is  switched  on  when 
the  organ  is  entered.  The 
room  must  be  dark.  It 
is  used  to  distinguish 
Dilatation  of  the  Stomach 
from  Gastroptosis.  An 
advantage  is  gained  by 
first  introducing  %  gn. 
of  Fluorescin  in  a  solution 
containing  glycerin  and 
soda,  the  gastric  juice 
being  neutralised  first 
with  15  grains  of  sodium 
bicarbonate  (Kemp). 


687-691 


THE  SWALLOW 


215 


692.  THE  SWALLOW 

In  the  act  of  swallowing,  the  soft  palate  is  raised  so  as  to  shut 
off  the  nasal  cavity ;  then,  breathing  being  arrested,  the  tongue 
presses  the  roof  of  the  mouth  and  the  jaws  meet.  The  nerves 
involved  are  the  superior  laryngeal  (afferent)  and  the  inferior 
laryngeal  (efferent). 

(Esophageal  dysphagia  is  usually  painless  and  followed  by 
regurgitation  ;  while  the  pharyngeal  form  is  painful. 


693.  Dysphagia  or  Difficulty  in 
Swallowing 

Angina  Ludovici 
„        (Esophageal 
.,        Pectoris 

Aorta,  Aneurysm  of 

,,        Descendens,      Aneu- 
rysm   of 

Arthritis,  Temporo-Max. 

Atlanto- axial  Disease 

Botulism 

Bronchial  Glands,  Enlarged 

Bulbar  Paralysis 

Cancer  of  Tongue,  Larynx, 
Pharynx,  or  (Esophagus 

Chorea 

Concretions  in  Tonsil 

Crico- arytenoid  Arthritis 
♦Diphtheria 

General  Paralysis 
-  Glandular  Fever 
*Glossitis 

Goitre  (x) 

Gumma  of  Pharynx 

Hemoglobinuria,     Paroxys- 
mal 

Herpes  of  Pharynx 

Hydropericardium 

Hydrophobia 

Hysterical  Globus 
*Impacted  Foreign  Body 

Laryngitis 


*  Laryngitis,   Tuberculous 

-  Lead-poisoning,   Severe 
Lingual  Tonsil,  Enlarged 
Lymphadenoma 

Lupus  of  Throat 

slight 

Measles 

Mediastinitis,    Acute 
Mercurial  Stomatitis 

—  Miculicz'    Disease 
Myasthenia  Gravis 
(Esophageal  Pouch 

*(Esophagismus 
*(Esophagitis 
(Esophagus,  Idiopathic  Dila- 
tation of 
,,  Stricture  of 

,,  Volvulus  of 

Pachydermia  Laryngis 

-  Palate,  Cleft 
Parotitis 
Pemphigus,  Buccal 

♦Pericardial  Effusion,   Large 
Perichondritis  of  Larynx 
violent  efforts 

Pharyngeal   Plaque    Muqu- 

euse 
♦Pharyngitis  Simplex 

Tuberculous 

—  Pharynx,    Stenosis    of 
Pleural  Effusion,  Large 

692-693 


216 


THE  SWALLOW 


Dysphagia  or  Difficuty  in 
Swallowing — continued 
*Post-pharyngeal  Abscess 
Ptomainism 
*  Quinsy 

Sarcoma  of  Pharynx 
*Scarlatina 
—  Spasm  of  Pharynx 
Stings 
Stomatitis 
Tongue,  Ulcerated 
^  Tetanus 
♦Tonsillitis  Simplex 
„  Rheumatic 

Gouty 


♦Tonsillitis,  Septic 
„  Syphilitic 

Tubercle  of  Pharynx 
Tumour  of  Mediastinum 
Trichinosis 
Typhus 

Variola  or  Varicella 
eruption  on  fauces 

♦Vincent's  Angina 

See  Paralysis  of  Degluti- 
tion (1327),  Regurgita- 
tion of  Food  (1116), 
Rumination  (1116),  and 
Spasm  of  Swallow, 
(1427) 


69a 


THE  LARYNX 


217 


THE  LARYNX 

694.  Laryngoscope. — For  laryngoscopic  examination  the 
disposition  of  the  sitters  is  similar  to  that  described  for  the 
opthalmoscope,  but  the  mirror  must  be  bound  to  the  surgeon's 
head  and  inclined  in  such  a  way  that  he  can  see  through  the  hole, 
and,  at  the  same  time,  without  any  constrained  position,  throw 
a  stream  of  light  on  to  the  pharynx  of  the  patient.  The  latter 
should  put  his  head  back,  open  his  mouth  wide,  protrude  his 
tongue,  and  hold  this  firmly  with  a  handkerchief  between  his 
finger  and  thumb,  thus  avoiding  the  necessity  for  the  use  of  a 
tongue  depressor.  The  surgeon  then  takes  a  medium-sized 
mirror  from  his  waistcoat-pocket,  where  it  has  been  kept  warm, 
and  puts  it  far  back  into  the  patient's  throat  until  it  rests  upon, 
and  slightly  raises,  the  base  of  the  uvula,  and  nearly  touches  the 
posterior  wall  of  the  pharynx.  The  patient  should  be  directed 
to  say  '  Ah-h-h.'  If  the  dorsum  of  the  tongue  is  alone  visible, 
the  handle  of  the  mirror  must  be  slightly  lowered ;  if  the 
epiglottis  is  in  the  way,  the  patient  should  say  '  E-e-e.' 

Kilian's  method  of  Direct  Laryngoscopy  by  means  of  a  grooved 
rectangular  spatula,  used  with  the  patient's  head  at  the  extreme 
point  of  retraction,  so  as  to  bring  the  mouth  in  a  line  with  the 
rima  glottidis,  is  said  to  have  some  advantages  in  the  diagnosis 
of  foreign  bodies  and  mediastinal  growths. 


695.  Ulcer  of  Larynx 

Cancer 

u  solitary 
Laryngitis,  Chronic  (x) 
Lupus 

much  scarring 

Syphilis 

deep,  with  sharply  defined 
edges,  multiple,  some 
cicatrised,  mucous  mem- 
brane red 

Tubercle 

shallow,  with  ill-defined 
edges,  esp.  about  aryte- 
noid cartilage  and  epi- 
glottis ;  mucous  mem- 
brane pale 


696.  Stenosis  or  Narrowing 

Cancer 
*Foreign  Body,  Impacted 
Growths,  Innocent 
Injuries,   Chemical   or   Me- 
chanical 
*Laryngitis 

simple,    or    in    connection 
with  diphtheria,  typhoid, 
variola,  etc. 
Leprosy 
Lupus 
*Paralysis  of  Abductors 
Perichondritis,  Acute 
Scars 
*Tertiary  Syphilis 
Tuberculosis 

694-696 


218 


THE  LARYNX 


697.  Growths 

Angeioma 
bleeding 
♦Cancer 

U  posterior  part  of  larynx 

Cysts 

Fibroma 

Papilloma 

Polypus 

Sarcoma 

698.  Laryngeal  Spasm 

Aneurysm 

Bronchial  Gland,  Enlarged 

Diphtheria 

Epilepsy 
♦Foreign  Body 

Growths 

Hydrophobia 

Hysteria 
♦Laryngismus  Stridulus 

Locomotor  Ataxy 
laryngeal  crisis 

Mediastinal  Tumour 
♦(Edema  Laryngis 
Tetany 

699.  Swelling       of       Mucous 
Membrane 

Generally  due  to  oedema. 

Angina  Ludovici 
Angio- neurotic  (Edema 
Cellulitis,  Cervical 
♦Diphtheria 
Enteric  Fever  (x) 


Erysipelas 
Foreign  Body 
Iodism 

Irritating  Gases 
Laryngitis,  Acute 
Laryngitis,  Tuberculous 
pale 

Lupus 

Nephritis 
♦(Edema  Laryngis 

Pachydermia 

Perichondritis 

Scalds 

Scarlatina 

Septic  Throat 
♦Tertiary  Syphilis 

Typhus 

Ulcers 

700.  Redness   of   Vocal  Cords 

Cancer 

often  unilateral 

Catarrh 
♦Laryngitis,  Acute 
Laryngitis,  Chronic 

patchy 
Tumours 
irritation    of 

701.  Membranous  Laryngitis 

♦Diphtheria 
Foreign  Body 
Irritant  Gases 
Measles  (x) 
Scalds 
Scarlatina  (x) 


697-701 


THE  LARYNX 


219 


702.  PARALYSIS,    LARYNGEAL 

The  crico-thyroid  muscle  is  supplied  by  the  superior  laryngeal 
nerve,  and  all  the  rest  of  the  muscles  by  the  recurrent  laryngeal. 
The  arytenoid  is  supplied  by  both. 


703.  Bilateral  Abductor  Para- 
lysis 

Paralysis  of  both  crico- 
arytenoideus  posticus 
muscles. 

Dyspnoea  very  marked. 

Bulbar  Paralysis 

Cancer  of  Cervical  Glands 

„     of  Thyroid 
Caries,  Cervical 
Degeneration     of     Vagus 

Centre 
Disseminated  Sclerosis 
General  Paralysis 
Locomotor  Ataxy 
Neuritis,  Alcoholic 

„        Arsenical 

„        Diphtheritic 

,,        Influenzal 

Syphilis 

Syringomyelia 

Also  the  diseases  given  under 
next  section  but  with  both 
cords  affected. 


704.  Unilateral  Abductor  Para- 
lysis 

Usually  due  to  pressure  upon 
the  recurrent  laryngeal 
nerve  and  practically  al- 
ways upon  the  left. 

Aneurysm  of  Aorta 
Cancer  of  (Esophagus 
Lymphadenoma 
Mediastinal  Fibrosis 
Mediastinal  Growth 

or  secondary  growth  in 
glands 

Phthisis,  Fibroid 
left  upper  lobe 


705.  Bilateral  Adductor 

Exhaustion 
*Hysteria 

Laryngitis,  Catarrhal 
Menopause 
Menses,  Suppressed 

In  functional  paralysis,  the 
patient,  though  voiceless, 
can  give  a  resonant  cough. 


706.  Unilateral  Adductor 

Catarrhal  Laryngitis 
Lead-poisoning 
Syphilitic  Laryngitis 
702-706 


220 


THE  LARYNX 


707.  Crico-thyroid  Paralysis 

Duo  to  pressure  upon,  or 
neuritis  of,  the  Superior 
Laryngeal  nerve. 

Aneurysm 

Bulbar  Paralysis 

Diphtheritic  Paralysis 

Locomotor  Ataxy 

Syringomyelia 


708.  Semon's  Sign 

Impaired    mobility    of    the 
vocal  cords  in  : — 

Carcinoma  of  Larynx 

But  it  occurs  also  in  chondral 
arthritis  and  as  an  effect 
of  cicatrices. 


(See   Dyspnoea,    1223;    Dysphagia,    693;    Voice,  1228;    and 
Cough,  1193) 


707  708 


THE    NECK 


221 


709.  THE  NECK 

A  long  neck  is  said  to  predispose  to  phthisis  ;    a  short  thick  one 
to  apoplexy.     Wasting  is  commonly  first  evident  in  the  neck. 


710.  Stiff 

Actinomycosis 
Angina  Ludovici 
Ankylosis  of  Spine 
Atlanto-axial  Disease 
*Carbuncles  or  Boils 
Caries  of  Cervical  Vertebrae 
Cerebellar  Tumour 
Cicatrices 

General  Paralysis  (x) 
Glands,  Inflamed 
Glandular  Fever 
Injuries 

Leptomeningitis,  Spinal 
Myositis  ossificans 
Neurasthenia,  Traumatic 

sometimes  with  audible  click 
on  movement 

Pachymeningitis,  Cervical 
Paralysis  Agitans 
Polymyositis 
Post-pharyngeal  Abscess 
*Rheumatism 
Rheumatoid  Arthritis 
Rotheln 

Spinal    Meningeal    Haemor- 
rhage 
,,       Meningitis 
„       Tumour 
Spondylose  Rhizomelique 
*Sprain 
Tetanus 
Tonsillitis 

*Torticollis,  Congenital 
„  Spasmodic 


711.  Wry     Neck     (Torticollis) 

Caries 

Cervical  Rib 
Congenital  Affection 
*Contraction  of  Scars 
Facial  Hemiatrophy 
*Hysteria 
Slipped  Tendon 
Spasmodic  Torticollis 
Sternomastoid,  Injury  to 
Tumour    of    Middle     Cere- 
bellar Peduncle 
and  other   subtentorial   tu- 
mours 

Worms 
*+*  '  There  is  no  such  thing  as 
paralytic  torticollis  ' 

(Gowers). 

Retracted    Neck   (see   Head, 
361) 

712.  Displacement  ol  Trachea 

*Aneurysm  of  Innominate 

to  left 
Cirrhosis  of  Lung 

towards    contracted    side 
Lymphadenoma 
Mediastinal  Tumours 

when  large 

713.  «  Tracheal  Tug  *  (Oliver's 
Sign) 

The  chin  should  be  raised 
in  order  to  see  or  feel  this. 
It  is  synchronous  with 
the  heart's   action. 

709-713 


222 


THE   NECK 


Tracheal  Tug — continued 
♦Aneurysm     of     Transverse 

Aorta 
Cancerous  Bronchial  Glands 
Dilatation  of  Aorta  (x) 
Pulsating   Mediastinal   Sar- 
coma 
Retraction  of  Left  Lung 


714.  Tumefaction    above    Cla- 
vicles 

Aneurysm  of  Aorta 

left  side  only 
Cretinism 

pads  of  fat 
Emphysema,  Interstitial 

from  cancer  of  oesophagus, 
etc. 

♦Emphysema,  Vesicular 
increased  on  coughing 


Myxcedema 


715.  Rotundity  of  One  Clavicle, 

Cirrhosis  of  Lung 
Collapse  of  Lung        f 
♦Phthisis 

Attention  has  not  hitherto, 
I  think,  been  directed  to 
this  symptom ;  but  it  is 
necessarily  more  obvious 
than  either  of  its  con- 
geners —  subclavicular 
flattening  or  supraclavi- 
cular retraction.  Norm- 
ally not  more  than  £  of 
the  rotundity  of  the  bone 
is  exposed,  whereas  bad 
cases  of  shrunken  apex 
may  show  f.  It  is  of 
most  value  when  uni- 
lateral. 


716.  Sterno-mastoid,    Swelling 
in 

Abscess,  Tuberculous 
Gumma 
♦Hematoma  (Infants) 

esp.  after  breech  presenta- 
tions 

717.  Sterno-mastoids,     Promi- 
nent 

Asthma 

Bronchitis,  Chronic 
♦Chronic  Dyspnoea  in  general 
(1223) 
Emphysema 

718.  Inspiratory  Retraction  at 

Episternal  Notch 

This  as  well  as  the  symptom 
which  follows  depends 
upon  the  volume  of  air 
inspired  being  insuffi- 
cient to  keep  pace  with 
thoracic  expansion.  The 
diseases  are  common  to 
both. 

719.  Inspiratory     Descent     of 
Pomum  Adami 

♦Asthma,  Spasmodic 

Cirrhosis  of  Lung 

Collapse  of  Lung 

Contraction  of  large  Vomica 
♦Diphtheritic  Laryngitis 
♦Obstruction  in  Air-passages 

(Edema  Laryngis 

720.  Demarquay's  Sign 

Immobility   or   lowering   of 
the  larynx  during  degluti 
tion. 

Tracheal  Syphilis 

713-720 


THE   NECK 


223 


721.  Throbbing  Carotids 

More    often    neurotic    than 
organic. 

Ague 
hot  stage 

*Anaemia 

Aneurysm 
*Aortic  Regurgitation 

Atheroma 

Cervical  Rib 

Excitement 

Exertion 
*Exophthalmic  Goitre 
*HEemorrhage,  Profuse 

Hyperaemia  of  Brain 

Hypertrophy  of  Heart 

Hysteria 

Menopause 

Neurasthenia 

Obliterated  Desc.  Aorta 

Pyrexia 
to  a  slight  extent 

722.  Distended  Jugular 

Aneurysm 

esp.  intra-pericardial 

*Asthma 

Broncho  -pneumonia 

Dilatation  of  Heart 

the  distension  is  increased 
by  compressing  the  liver 

*Dyspncea,  Acute  (1223) 
Mediastinal  Disease 
(Edema  of  Lungs 
Pericardial  Effusion,   Large 
Pericardium,  Adherent 
collapsing  with  diastole 

Post-pharyngeal  Abscess 
*Straining 
Thymus,  Enlarged 


723.  Jugular  Vein  Empty 
Adhesive  Pericarditis  (x) 
Thrombosis  of  Lateral  Sinus 


724.  Kussmaul's  Sign 

Inspiratory       swelling 
Jugular  Vein 

Adhesive  Pericarditis 


of 


725.  Pulsating  Vein 

Best  seen  on  right  side  ; 
the  patient  should  usually 
be  recumbent.  It  gener- 
ally implies  dilatation  of 
the  right  auricle.  When 
not  due  to  transmission 
from  the  carotids,  the 
pulsation  will  cease  when 
the  vein  is  compressed 
high  up. 

Anaemia 

Aortic  Aneurysm 

when  communicating  with 
superior  vena  cava 

*Aortic  Regurgitation    (late) 
„       Stenosis  (late) 
Cachexia,  Cancerous 
Chlorosis 
Cirrhosis  of  Liver,  Atrophic 

better  seen  in  vein  of 
forearm 

*Dilatation  of  Heart 
Fatty  Heart 
Hypertrophy     of     Right 

Ventricle 
Malformation  of  Heart 
Mediastinitis 
inspiratory 

721-725 


224 


THE   NECK 


Pulsating  Vein — continued 
Mitral  Stenosis 
Myocarditis,  Chronic 
Patent  Foramen  Ovale 
Pericarditis,  Adhesive 
♦Pernicious  Anaemia 
Pregnancy 
Stokes-Adams'    Disease 


Tricuspid  Regurgitation 

systolic 
Tricuspid  Stenosis 
erect    position    only — pre- 
systolic. 
Venous     pulsation      occurs 
sometimes  in  healthy  per- 
sons when  the  breath  is 
held.     (See  269,  283.) 


Fig.  5. — Venous  Pulse  in  the  Jugular,  and  its  Time  Relations 
to  the  Apex  Beat  and  the  Carotid  and  Radial  Pulses. 

The  perpendicular  lines  show  the  time  of  : — 

(1)  Beginning  of  auricular  systole. 

(2)  „        „   ventricular  systole. 

(3)  „        „   carotid  pulse. 

(4)  „         „   radial  pulse. 

(5)  Closure  of  semilunar  valves. 

(6)  Opening  of  tricuspid  valve. 

From   '  Diseases    of    the  Heart,'   by  James    Mackenzie,   M.D., 
F.R.C.P.     (Hodder  &  Stoughton.) 


726.  Branchial  Fistula 

A  fine  opening  just  above 
sterno-clavicular  articula- 

I  tion,  or  else  on  a  level 
with  the  top  of  the  thy- 
roid cartilage. 

Congenital  condition 


727.  Enlarged  Glands 

The  loss  of  subcutaneous 
fat  which  occurs  in  wast- 
ing disease  may  give  a 
fictitious  appearance  of 
enlargement. 


725-727 


THE  NECK 


225 


728.  Enlarged   Parotid 

Cancer 

Cholera 

Dysentery 

Exanthemata  (x) 

Miculicz'  Disease 
*Mumps 

Orchitis 
♦Septicaemia 

Tumour 

There  is  also  a  lymphatic 
gland  here.  Its  vessels 
come  from  the  upper 
pharynx,  the  nasal  fossae, 
and  the  frontal  and 
parietal   scalp. 


729.  Enlarged    Submaxillary 
Glands 

They  receive  the  lymphatics 
from  the  skin  of  the  face 
and  neck,  the  larynx, 
fauces,  lower  lip,  buccal 
cavity,  lower  gums,  and 
front  of  tongue,  and  will 
be  enlarged  by  irritation 
within  this  area. 

Actinomycosis 
Angina  Ludovici 
around  gland 

Boils 

Cancer 

*Carious  Lower  Teeth 
*Diphtheria 

Epithelioma 

Gummatous  Ulcer 

Malta  Fever 

Miculicz'  Disease 

Mumps 

Quinsy 

Roseola 

Scarlatina 


♦Stomatitis 
♦Syphilis 

Symmetrical  Adeno-lipoma- 

tosis 
Tonsillitis 
Vincent's  Angina  (x) 

The  suprahyoid  glands  also 
receive  lymphatics  from 
the  front  of  the  tongue 
and  the  lower  lip. 

730.  Enlarged  Supraclavicular 
Glands 

When  these  alone  are 
affected,  the  significance 
is  more  definite.   Thus  : — 

Left  side — 
*  Cancer  of  Breast,  n. 
Cancer,  Secondary 

chiefly  abdominal,  pelvic, 
and     testicular     growths 

Tuberculosis 
Right  side — 

Cancer  of  Breast,  n. 
Cancer,  Secondary 

chiefly     intrathoracic    or 
oesophageal  growths 

When  they  are  affected 
in  conjunction  with  other 
glands,  sections  729  and 
731  will  apply. 

731.  Enlarged  Cervical  Glands 

The  lymphatics  of  the  skin 
of  the  face  and  neck  and 
of  the  external  ear  and 
scalp  go  to  the  superficial 
set  those  of  the  buccal 
cavity,  root  of  tongue, 
tonsils,  palate,  pharynx, 
larnyx,  orbit,  and  nasal 
fossae  to  the  deep  set. 
Irritation  within  these 
areas  may  cause  their 
enlargement. 

728-731 


226 


THE  NECK 


Enlarged  Cervical  Glands 
— continued 
*Boils 
Cancer  in  above  area 
Carbuncle 
*Carious  Teeth 
Diphtheria 
esp.  intercarotid  gland 

*Ecthyma 
Eczema 
Erysipelas 
Glanders 
Glandular  Fever 
Hooping  Cough. 
Leukaemia 
Lymph  adenoma 
Lymphosarcoma 
Malta  Fever 
Measles 

Parinaud's  Conjunctivitis 
Perichondritis  syphilitica 
Phthisis 

Plague,  Bubonic 
Post-pharyngeal  Abscess 
Quinsy 
Roseola 
Rotheln 

esp.  those  in  posterior  tri- 
angle 

Scarlatina 

Status  Lymphaticus 
Syphilis 

Thrombosis  of  Lat.  Sinus 
*Tubercle 
Vincent's  Angina 
slight 

Varicella 
Variola 
*Wounds 


732.  Enlarged  Occipital  Glands 

The  lymphatics  of  the 
posterior  portion  of  the 
scalp  terminate  here  and 
enlargement  is  generally 
caused  by  irritation  in 
that  region. 

Dermatitis,  Seborrhceic 
*Eczema  Capitis 

Leukaemia  (x) 

Lymphadenoma 
*Pediculosis  Capitis 
*R6theln 

Symmetrical    Adenolipoma- 

tosis 
*Syphilis 

Trypanosomiasis 

Tuberculosis 


733.  Thyroid  Enlarged 

Thyroid  swellings  move 
with  deglutition.  The 
right  lobe  is  normally 
the  larger. 

Abscess, 

single  or  multiple 

Adenoma 

Aneurysm 

Calculus  of  Thyroid 

Cancer  of  Thyroid 

*Cysts,  Simple 

*Exophthalmic  Go'tre 

unequal — pulsating 

*Fibrosis  of  Thyroid 
*Goitre,  Parenchymatous 

Gummata 

Hydatid  Cysts 
*Hypertrophy,  Simple 

Menopause 

Pregnancy 

unless  albuminuria  is 
present 

731-733 


THE    XECK 


227 


Thyroid      Enlarged — con- 
tinued 
Rheumatism,  Acute.  I. 
in  children 

Status  Lymphaticus 
Tubercle 

Al^o  in  lymphadenoma  and 
other  tumours  of  the  neck 
— from  pressure  on  veins. 
It  is  not  uncommon 
temporarily  in  febrile 
conditions  and  during 
menstruation. 


734.  Thyroid  Shrunken 
Acromegaly  (x) 
Cretinism 


*Myxcedema 


735.  Enlarged  Thymus 

Acromegaly 
*Exophthalmic  Goitre 

Leuksemia 

Lymphadenoma 

Myasthenia  Gravis 
*Status  Lymphaticus 
*Thymic  Asthma 

***  The  thymus  is  atrophied  in 
marasmus.  It  is  largest 
proportionately  to  the 
body  weight  at  between 
2  and  4  years  of  age. 


736.  Swellings    in    Neck    (Un- 
classified) 
*Abscess 
Aneurysm 
Angina  Ludovici 
Branchial  Cyst  (741) 
Bursa,  Hyoid 
„      Thyroid 
Carotid    Body,    Tumour    of 
Cervical  Rib 
Chloroma 
Cysts,  Dermoid 

,,  Sebaceous 
Fractured  Hyoid 
Hydrocele  of  the  Xeck 

behind   the   sterno-mastoid 
Jugular  Bulb 
*Lipoma 

„         Diffuse 
Madelung's  *  Fetthals  '' 
Mastoiditis,  Bezold's 
beneath  sterno-mastoid 

Mediastinal  Abscess 
Multilocular  Cyst 
Myositis  Ossificans 
Perichondritis,  Suppurative 
Pneumatocele 
Pouch,  (Esophageal 
Ranula,  Large 
Sarcoma 
Thyroglossal  Cyst 


Q  2 


733-736 


228  CHEST 

737.  THE   REGIONS   OF  THE  CHEST 

The  old  regions  of  the  chest,  which  are  indicated  by  the  dotted 
lines  on  the  figure,  are,  from  above  downwards,  the  supra- 
clavicular, clavicular,  infraclavicular,  mammary,  and  the 
hypochondrium.  But  they  are  so  large  as  to  be  of  little  practical 
use.  What  is  wanted  is  the  division  of  the  chest  into  spaces 
small  enough  to  be  covered  by  the  chest-pieee  of  a  stethoscope, 
and  yet  bounded  by  well-known  and  easily  remembered  lines. 
Further,  each  region  should  be  numbered,  so  that  the  cumber- 
some use  of  such  terms  as  finger-breadths  and  inches  from  more 
or  less  fixed  spots  may  be  avoided  and  a  simple  formula  sub- 
stituted. I  have  endeavoured  to  supply  this  want  by  taking  a 
map  as  a  model.  The  zones  or  '  degrees  of  latitude '  are  formed 
by  the  ribs  and  intercostal  spaces,  the  columns  or  '  degrees  of 
longitude '  by  the  area  between  well-known  vertical  lines.  The 
new  region  is  the  square  produced  by  the  intersection  of  column 
and  zone. 

Each  vertical  line  is  marked  with  one  letter  :  thus  P  for 
Parasternal,  M  for  Mammillary ;  each  vertical  column  is  indicated 
by  two  letters  :  thus,  PS  for  Parasternal  Column,  IM  for  Internal 
Mammary,  EM  for  External  Mammary,  etc.  The  zones  are 
marked  in  figures,  each  rib  bearing  its  own  number,  and  each 
intercostal  space  having  x  added  to  its  number  ;  but,  since  the 
first  rib  is  too  deep  to  be  of  use,  the  figure  1  is  placed  on  the 
clavicle,  while  0  marks  the  supraclavicular  region.  The  inter- 
section of  column  and  zone  or  of  fine  and  zone  forming  the  new 
region  receives  for  its  designation  the  number  and  letter  of  its 
congeners.  Thus  the  region  marked  in  the  woodcut  +  is  IM5a; 
(Internal  Mammary  column  and  fifth  intercostal  space),  while 
that  marked  0  is  M8,  or  the  intersection  of  the  mammillary 
line  with  the  eighth  rib,  and  they  will  be  so  entered  in  the  case- 
book. In  some  cases  still  greater  precision  may  be  necessary, 
and  this  is  attained  by  the  addition  of  +  or  —  ;  plus  meaning 
nearer  the  periphery,  minus  nearer  the  middle  fine  (note  the 
alliteration).  The  position  of  figure  6,  for  instance,  on  the  sixth 
left  rib  would  be  exactly  described  by  the  formula  IM+6  Left. 

Instead,  therefore,  of  fourteen  unwieldy  regions,  the 
boundaries  of  many  of  which  are  difficult  to  memorise,  the 
system  gives  us  between  three  and  four  hundred  compact 
spaces,  each  capable  of  being  described  by  a  simple  and  easily 
remembered  formula  (Q.E.F.). 

737 


CHEST 


229 


Tig.  6. — A  New  Regional  Chart  of  the  Chest. 

Based  on  the  geographical  system  of  latitude  and  longitude.     See  737 


230 


CHEST 


738.  INSPECTION   OF  THE    CHEST 

The  first  rib  is  practically  hidden  by  the  clavicle ;  the  position 
of  the  second  is  indicated  by  the  manubrio-sternal  prominence, 
and  the  eleventh  and  twelfth  are  known  by  their  free,  unattached 
extremities.  The  patient  should  stand  at  '  attention,'  with  feet 
together,  head  raised,  and  shoulders  squared.  The  chest  measure- 
ment should  be  not  less  than  half  the  height.  People  with  a  con- 
tracted chest  are  sometimes  compensated  by  its  exaggerated  length, 
and  are  all  the  better  '  lives  '  in  consequence. 


739.  Affections  of  Chest  Walls 

Abscess,  Intrathoracic 

pointing 
Abscess,  Necrosis 

,,  Superficial 

Callus  from   Fracture 
Empyema  Necessitatis 
Intercostal  Neuralgia 

,,  Rheumatism 

Perichondritis 
Periostitis 

(See  Skin,  313) 

740.  Flat  Chest 

Predisposition  to  Phthisis 
Progressive  Muscular  Atro- 
phy 

741.  Pterygoid  Chest 

Projecting  shoulder-blade. 

Cyphosis  (812) 

Landouzy  -  Dejerine     Para- 
lysis 

Latissimus  Dorsi,  Slipped 

Predisposition  to  Phthisis 
both  scapulae 

Serratus  Magnus  Palsy 

742.  Pigeon-Breast    or    Pectus 
Carinatum 

Generally  due  to  inter- 
ference with  lung  expan- 
sion in  childhood.  It 
has  been  thought  to 
predispose  to  phthisis. 


Adenoids 

Catarrhs,  Repeated 

Hooping  Cough 

Rickets 

Tonsils,  Enlargement  of 

743.  Zonal  Constriction  (Harri- 
son's Sulcus) 

History  of  repeated  catarrhs 
or  of  other  impediments 
to  inspiration,  especially 
in  rickety  subjects  with 
prominent  abdomens. 

744.  Barrel-shaped 

Emphysema 

745.  Angulus   Ludovici 

A  prominence  of  the  manu- 
brio-sternal   joint    which 
thus  forms    a    projecting 
angle. 
Emphysema 

746.  Rosary  Chest 

Knobby      enlargement     at 
junction     of     ribs     with 
costal  cartilages. 
Achondroplasia 
Infantile   Scurvy 
*Rickets 

747.  Red  Zone 

Seen     al  ng     the     line     of 
attachment    of   the    dia- 
phragm. 
Ventricle,  Dilated  Right 
if  strained 

738-747 


CHEST 


231 


748.  BULGING 

The  shape  of  the  chest  is  best  ascertained  by  Dr.  Gee's  cyrtometer, 
which  consists  of  a  stretched  piece  of  soft  metal  gas  tube. 


749.  Of  Entire  Side 
Cirrhosis  of  Lung 

sound  side 
Empyema 
Haemothorax 

Infiltrated  Cancer  of  Lung 
♦Pleural  Effusion 

semicylindrical 

Pneumothorax 
Pleura,  Cancer  of 

750.  Circumscribed  Bulging 

Abscess,  Hepatic  (x) 
„         of  Chest  wall 
♦Aneurysm  of  Ascending  Aorta 

intra-pericardial,  right  nipple ; 
extra-pericardial,         fourth 
right  cartilage 
Aneurysm     of      Transverse 
Portion 
above  left  clavicle 

Caries  of  Sternum 

Encysted  Pleurisy 

♦Empyema,  Pointing 

'  Empyema  necessitatis  ' 
Heart,  Hypertrophied 
in  children 

Hernia  of  Lung 

impulse  on  coughing 
Hydatids  of  Lung 
Mediastinal   Abscess 

above  or  at  side  of  sternum 
Mediastinal  Tumour 
Necrosis  of  Ribs 
Osteomyelitis  of  Ribs 
a  sequel  of  enteric 


Pyopneumothorax 
Rickets  (x) 
Thymus,  Enlarged 

inspiratory  sternal  bulgo 
Tubercle  of  Ribs 
Tumour  of  Chest -wall 

(See  also  751) 

751.  Prsecordial  Bulging 

Most  marked  in  children. 
Acromegaly 

inferior  sternal 
♦Aneurysm  (MO) 
Aortic  Regurgitation  (x) 

,,      Stenosis 
Dilatation  of  Heart 
Exophthalmic  Goitre 
Hypertrophy  of  Heart 
Malformation  of  Heart 
Mediastinal  Tumour 
Mitral  Stenosis 

slight 

♦Pericardial  Effusion 
Pneumopericardium 
Pyopericardium  (x) 

752.  Bulging  of  Right  Hypo- 
chondrium 

Abscess,  Hepatic 

Enlarged  Liver 

Hydatids 

Pleural  Effusion  (rt.) 

753.  E wart's  Sign 

Prominence  of  sternal   end 
of  left  first  rib 

Pericardial  Effusion 

748-753 


232 


CHEST 


SHRINKING 


754.  Of  Entire  Side 

The  left  side  is  normally 
smaller  than  the  right. 

Aneurysm 

if  occluding  bronchus 
Cirrhosis  of  Lung,  n. 

contraction  stage 

Collapse  of  one  Lung 

Empyema  (x) 

Hemiplegia 

Infiltrated  Cancer  of  Lung 

(x) 

with  collapse  of  air-cells 

Mediastinal  Tumour 
if  occluding  bronchus 

*Pleurisy,  Old 
Pyopneumothorax  (x) 

Shrinking  may  be  caused 
or  simulated  by  scoliosis 
(814). 

755.  Foveated  or  Funnel  Chest 
( '  Trichterbrust ' ) 
Lower  sternal  region. 

♦Adenoids 
♦Enlarged  Tonsils 


Nasopharyngeal   Growths 

Pericardial  Adhesion 

Pleurisy,  Old  Double 

Rickets 

A  similar  depression,  but 
lower,  occurs  in  shoe- 
makers from  the  pressure 
of  the  last,  '  cobbler's 
chest,'  or '  Schusterbrust.' 

756.  Sternum  Sunken 

('  Thorax  en  bateau  ') 
Infantile  Scurvy 
♦Syringomyelia 

757.  Local  Flattening 

Bronchiectasis 
Collapse  of  Lung 
Contraction  of  Vomica 
Fibroid  Lung 
♦Phthisis 

infraclavicular 

753.  Rothschild's  Sign 

Preternatural  flattening  and 
mobility  of  the  sterno- 
costal angle. 

Phthisis,  Early 


INTERCOSTAL  SPACES 


759.  Bulging  Spaces 
Empyema,  I. 
Hemothorax  (x) 
Hydatids  of  Lung 
Hydrothorax 
Mediastinal  Abscess 

pointing 
Mediastinal  Tumours 


♦Pleurisy  with  Effusion 
Pneumothorax 
Pyopneumothorax 

760.  Spaces    Retracted    with 
Inspiration 

Asthma,  Spasmodic 
Cancer  of  Larynx 

754-760 


CHEST 


233 


Spaces  Retracted  with  In- 
spiration — continued 

Cirrhosis  of  Lung 

Collapse  of  Lung 
♦Diphtheritic  Laryngitis 

Emphysema 
♦Foreign  Body  in  Air-passage 

Occlusion  of  Bronchus 

(Edema  Laryngis 

Paralysis  of  Diaphragm 

epigastrium,  also 


761.  Precordial  Retraction  of 
Spaces 
Aortic  Regurgitation 

systolic 
Mitral  Stenosis 
diastolic 
♦Pericardial  Adhesion 

systolic — apex,  xiphoid  car- 
tilage, and  epigastrium 

Retraction  of  Lung 


762.  Systolic      Retraction     of 

Lower  Ribs 

('  Friedreich's  Retraction 
Sign '  and  '  Solovieff's 
Phenomenon.') 

Hypertrophy  of  Heart   (x) 
♦Pericardium    Adherent    to 
Diaphragm 
Tetany 

763.  Stiller's  Sign 

Increased  mobility  of  the 
tenth  rib. 

Enteroptosis 

764.  Diaphragm  High 

♦Ascites 
Collapse  of  Lung 
Contraction  of  Lung 
Dilatation  of  Stomach 
Paralysis  of  Diaphragm 
Pregnancy 

Tumours,  Abdominal 
Tympanites  (1700) 


765.  Diaphragm  Low 

Enteroptosis 

Hypertrophous  Emphysema 
Hypertrophy  of  Heart 
Mediastinal  Tumours 
Pericardial  Effusion 
♦Pleural  Effusion 
Spasm  of  Diaphragm 

766.  Diaphragm    Phenomenon 

Absent  on  One  Side 

On  looking  obliquely  at 
the  patient's  side  from 
a  distance,  the  move- 
ment of  the  lung  where 
it  follows  the  descent  of 
the  diaphragm  should  be 
visible.  This  is  termed 
the '  diaphragm  phenome- 
non' or  Litton' s  Sign. 

Cancer  of  Pleura 

Cirrhosis  of  Opposite  Lung 

Cord  Lesion,  Unilateral 

Empyema 

Hydrothorax 

Phrenic  Paralysis 

Pleuritic  Adhesions 

,,         Effusion 
Pneumonia 
Pneumothorax 

760-766 


234 


CHEST 


767.  Impaired  Chest  Mobility 

With  or  without  belated 
expansion . 

There  should  be  a  difference 
of  not  less  than  2  inches 
in  measurement  between 
the  inflated  and  the  col- 
lapsed chest,  the  average 
being  2*4  inches.  The 
expansion  of  the  five 
lower  ribs  is  caused  by  the 
diaphragm 

Atelectasis 
Bronchus,  Occluded 
Cancer  of  Lung 
Cirrhosis  of  Lung 
Empyema 
Epilepsy 
♦Fractured  Ribs 
Hydrothorax 
Intercostal  Neuralgia 

*  „  Paralysis 

*  „  Rheumatism 
Liver,  Great  Enlargement  of 
Mediastinal  Tumour 
Pericardium,  Adherent 
Phthisis 

esp.  under  clavicle 
Pleural  Adhesion 
Pleurisy,  Acute 
♦Pleurisy  with  Effusion 
Pneumonia 

base 
Pneumonic  Consolidation 


♦Pneumothorax 
Spasm  of  Glottis 

,,        of      Respiratory 
Muscles 
Strychnine-poisoning 
Tetanus 
***  Also  when  the  costal  carti- 
lages are  ossified,    as    oc- 
curs sometimes  in  Exoph- 
thalmic   Goitre  (Bryson's 
Sign). 

768.  Enlarged  Veins  of  Chest 

The  enlargement  is  bilateral 
when  the  obstruction  is  in 
one  vena  cava  ;  unilateral 
when  in  one  vena  innom- 
inata. 
Aneurysm  of  Aorta 
Cancer  of  Breast 
Dilatation  of  Heart 
♦Lactation 

♦Mediastinal  Tumour 
flow  usually  downwards 
Mediastinitis,   Chronic   Fib- 
rous 
♦Mitral   Regurgitation 

late 
♦Portal        Obstruction        or 
Thrombosis 
flow  upwards 
Thrombosis  of  Vena  Cava 
„  of   Vena   Inno- 

minata 


767-768 


CHEST 


235 


769.  MAMMA 


The  nipple  of  a  breast  which  is  inflamed,  tuberculous,  or  the 
seat  of  a  tumour,  stands  at  a  higher  level  than  the  other.  Adhesions 
to  pectoral  fascia  or  skin,  and  also  puckers  and  dimples,  point  to 
advanced  carcinoma.  The  hypodermic  syringe  will  help  in  the 
diagnosis  of  a  cyst. 


770.  Milk  in  Breasts 

Acromegaly 
Ectopic  Gestation 
Galactocele 
on  squeezing  swelling 

*Lactation 

Ovarian  Cysts 

Pregnancy 

It  is  not  uncommon  in  newly 
born  infants,  male  as  well 
as  female,  and  has  been 
observed  in  adolescent 
virgins  and  in  sexagen- 
arian women. 


771.  Milk,  Abnormal 

Black 

Aspergillus  niger 
Blue 

Bacillus  pyocyaneus 

Green 

Actinomycosis 

Purulent 

Abscess 

Red 

Micrococcus   prodigiosus    or 
blood 

Yellow 
Jaundice 
***  Lead  and  arsenic  poisoning 
may   be   transmitted    by 
the  milk. 


772.  Mammary  Swelling 

*  Abscess,  Mammary 
,,  Submammary 

,,  Tuberculous 

Actinomycosis 
*Adenoma 
Carcinoma,  Acute 
'  peau  d'orange  ' 

Colloid  (x) 
*Cyst 

often  multiple 

Encephaloid  (x) 
Enchondroma  (x) 
Fibro  -Adenoma 

This  includes  the  '  Painful 
Mammary  Tumour.' 

Galactocele 
Hsematoma 
Intestinal  Stasis 
mastitis 

Lipoma 

Lobular  Induration 

Mastitis,  Interstitial 

Osteoma 
*Papilloma  of  Duct 

Sarcoma 
*Scirrhus 

Tuberculous  Growth 


769-772 


236  CHEST 

773.  Oozing,  Sanguineous  775.  Pigmentation     around 

Cancer  of  Duct  Nipples 

Nipple,  Cracked  Ectopic  Gestation 

Papilloma  of  Duct  Ovarian  Cyst 

Sarcoma  *Pregnaney 
Vicarious      menstruation 

from  the  nipple  is  a  well-  776#  paget's  Nipple 
established  rarity. 

Forerunner  of  cancer;    but 

__.     _     .  .  now  said  to  be  cancerous 

774.  Oozing,  Purulent  from  the  outset. 
Abscess 

Mastitis,  Tuberculous  Axillary  Glands,  see  874. 

Sebaceous  Cyst,    Suppurat- 
ing 


773-776 


PAPvACRXTESrS 


237 


777.  PARACENTESIS    OF   CHEST 

For  diagnostic  purposes,  a  sterilised  hypodermic  syringe 
will  suffice,  the  skin  having  been  surgically  washed  first.  The 
puncture  for  the  pleura  is  best  made  in  the  sixth  or  seventh 
interspace  in  the  midaxillary  line  ;  for  the  pericardium,  in  the 
hfth  space  two  finger-breadths  from  the  left  margin  of  the  sternum 
(P5x  in  chart — Fig.  6).  The  specific  gravity  is  lower  in  transu- 
dates than  in  exudates. 


778.  Air  or  Gas 
Decomposition 

Bacillus  Aerogenes  (a  in- 
sula t  us  ;   B.  Coli. 

Pneumothorax 

Puncture  of  Lung 

blood-stained  bubbles 

779.  Serum  or  Clear  Fluid 
Acute  Pleurisy   or  Pericar- 
ditis 

sp.  gr.  over  1017,  highly 
albuminous ;  polynuclear 
leucocytes 

Cancer  of  Pleura  or  Cancer  of 
Lung 

'  prune- juice  '  or  greenish 
brown,  but  may  be  clear 
— albuminous 

Hydatids 

hooklets 

Hydrothorax 

sp.  gr.  under  1015,  little  or  no 
albumen,  endothelial  cells 

Nephritis, 

PleurisjT,  Tuberculous 

albuminous ;  lymphocytes 
numerous  after  first  few 
days 

Portal  Stasis 
a  little  albumen 

Rheumatism,  Acute  (x) 


780.  Pus 

Abscess.  Pulmonary,  Hepatic 

or   Subphrenic 

bursting  into  pleural  cavity 
— often  putrid 

Actinomycosis 

greenish  with  yellow  seed- 
like bodies 

*Empyema 
Gangrene  of  Lung 
putrid 

Hydatids,   Suppurating 
hooklets 

Septicaemia 

The  organisms  found  in 
pus  include  Streptococci, 
Staphylococci,  Pneumo- 
cocci,  B.  Tuberculosis,  B. 
Cob,  B.  Influenza?,  Amseba 
Cob,  Actinomyces,  and 
Hydatids  (or  hooklets). 

,  781.  Blood 

Blood-stained  froth  indi- 
cates that  the  lung  has 
been  punctured. 

Aneurysm,  Bursting 
Encephaloid   Lung 
or  '  prune  juice  ' 

*Haemophilia 

♦Myelosarcoma,   Secondary 
777-781 


238 


PARACENTESIS 


Blood — continued 
Purpura 
Scurvy- 
Trauma 

including  a  wound  from  a 
previous  paracentesis 

Tuberculous  Pleurisy  (x) 

Particles  of  a  growth  are 
sometimes  found  on  cen- 
trifuging  after  dilution. 


782.  Chyle 

Pleura,  Carcinoma  of 
Rupture  of  Thoracic  Duct 

783.  Pfuhl's  Sign 

Inspiration  increases  the 
force  of  flow  in  paracen- 
tesis of  Subphrenic  Abs- 
cess, but  lessens  it  in  that 
of  Pyopneumothorax. 


PARACENTESIS   PERICARDII 


784.  Clear  in  acute  per' carditis 
and  hydrothorax. 

785.  Purulent  in  acute  infec- 
tion,     abscesses,     septic 

.   cases,  and  tuberculosis. 


786.  Hsemorrhagic  in  cancer, 
ruptured  heart,  aneurysm, 
haemophilia,  purpura, 
scurvy,  and  trauma. 


787.  PARACENTESIS    ABDOMINIS 

The  pupcture  for  ascites  is  made  half-way  between  the 
umbilicus  and  the  pubes.  The  abdomen  should  be  supported 
by  a  many-tailed  bandage. 

CHARACTER   OF   FLUID 


788.  Gelatinous 

Colloid  Growth 

789.  Clear 

Ascites 

thin,  clear,  and  yellow 
Cyst,  Simple  Renal 

clear  ;  no  uric  acid 
Hydronephrosis 

murexide  test  positive 

Ovarian  Cyst 
viscid  and  green  or  brown 


Parovarian  Cyst 
watery    and    colourless,    or 
sometimes  brownish 

790.  Hemorrhagic 

Cancer 

u  of  omentum 

Peritonitis  Acute 

highly  albuminous  ;  sp.  gr. 
over  1015,  as  in  other 
inflammatory  conditions 

Peritonitis,  Tuberculous 

B.  Tuberculosis  (x),  or 
guinea- pig  inoculation  test 

(See  1821) 

781-790 


PARACENTESIS 


239 


791.  Purulent 

Peritonitis 
Tuberculous  Abscess 


792.  Gaseous   (usually  mixed) 
Cancer    of     stomach     or 

cesojmagus ;  a  vomica  or 
wound  penetrating  the 
lung. 

793.  Chylous 
Filariasis 
Obstruction    of    Thoracic 

Duct 
Rupture  of  Thoracic  Duct 
Leukaemia,  Myeloid  (x) 


794.  Milky     (not     chylous) 
Fatty  Degeneration  of  endo- 
thelial or  cancer  cells. 


795.  Glycogenic 

Watory  and  either  colour- 
less or  yellow.  Turns 
starch  into  sugar. 

Pancreatic  Cyst 

796.  Hooklets 

Hydatid  Cyst 

fluid  watery  and  only 
slightly    albuminous 

Cases  to  be  avoided  are  dis- 
tended bladder,  hydro- 
nephrosis, and  distended 
gall-bladder  (not  always 
showing  bile). 

797.  Rivalta's  Test 

The  presence  of  seromucin 
implies  an  inflammatory 
exudate.  If  a  drop  of  a 
2  per  cent,  solution  of 
glacial  acetic  acid  is  let 
fall  into  the  fluid,  a  white 
cloud  will  form  in  the  trail 
of  the  descending  drop. 


798.  LUMBAR    PARACENTESIS 

The  puncture  is  made  on  the  level  of  the  top  of  the  third  lumbar 
spine,  a  little  to  the  side  towards  which  the  patient  is  lying. 


Cerebrospinal  Fluid 

799.  Normal 

In  general  when  there  is  no 
organic  lesion  of  the 
meninges. 

Deep  Cerebral  Tumours 

„  „       Haemorrhages 

Epilepsy 
Hysteria 

Peripheral  Neuritis 
Syringomyelia 


800.  Lymphocytosis 
(a)  Moderate 

(50  to  200  per  cubic  mm.) 
Acute   Softening 
Alcoholic  Meningitis,  Chr. 
Disseminated  Sclerosis 
General  Paralysis 
Hypertrophic  Meningitis 
Poliomyelitis,  Anterior 

fluid  clear 

Superficial  Gummata 
,,  Tumours 

Syphilis 

791-800 


240 


PARACENTESIS 


Lym  phocytosis — con  tin  u ed 

(b)  Excessive 

Cerebro -spinal  Meningitis 

10,000  to  100,000  per  cubic 

mm.  plus  Weichselbaum's 

diplococcus.     Fluid   turbid. 

Tuberculous  Meningitis 

1000  per  cubic  mm.  plus 
bacillus  tuberculosis 

%*  In  fracture  of  the  skull, 
blood  is  found  ;  in  Puru- 
lent Meningitis,  pus ;  and 
in  Tumour  of  the  Brain 
sometimes  sugar. 

801.  Spirochaeta  Pallida 
General  Paralysis 

found  too  in  the  brain 

Locomotor  Ataxy 

Syphilis 

Congenital,  primary  and 
secondarj^.  Less  evident 
in  tertiary  syphilis. 

802.  Ross-Jones'  Test 

A  greyish  cobweb-like  ring 
forms  when  a  little  clear 
cerebro-spinal     fluid     is 


poured  gently  upon  a 
saturated  solution  of  am- 
monium sulphate.  It  is 
best  seen  against  a  black 
background. 

Acute  Infectious  Diseases  (x) 

General  Paralysis 

Gummata 

Locomotor  Ataxy 

Syphilis  of  Nervous  System 

803.  Noguchi's  Test 

This  depends  upon  the 
presence  of  globulin  in 
the  cerebro-spinal  fluid 
in  parasyphilitic  diseases, 
and  is  used  to  distinguish 
General  Paralysis  from 
other  forms  of  insanity. 

804.  Inoculation  Test 

Cerebro-spinal  fluid  taken 
several  days  before  the 
appearance  of  paralytic 
symptoms  and  injected 
into  a  monkey,  produces 
paralysis  within  seven 
days. 

Poliomyelitis,  Ant.  Acute 


805.  PARACENTESIS  CEREBRI 

This,  though  it  involves  trephining,  has  been  largely  used  by 
Prof.  Pfeiffer  for  the  diagnosis  of  abscesses,  cysticerci,  etc. 


800-805 


Fig.  7. — View  of  the  Visceea,  etc.,  from  behind 
(Treves  after   Rudinger) 

a,  pharynx ;  6,  innominate  artery ;  c,  subclavian  artery ;  d,  oeso- 
phagus, with  the  aorta  and  thoracic  duct  on  one  side  and  the 
azygos  vein  on  the  other  ;  e,  lungs  ;  /,  diaphragm  covering  liver  ; 
g,  kidney ;  h,  on  peritoneum,  points  to  spermatic  vessels  crossed 
by  ureter ;  i,  os  innominatum  above  sacro -iliac  synchondrosis ; 
jt  psoas ;  k,  gluteus  medius ;  I,  gluteus  maximus ;  m,  rectum 
and  superior  hemorrhoidal  artery. 

R  i 


242 


SPINE 


INSPECTION  OF  THE 


806.  Stiffness 

Ankylosis  of  Spine 
Caries  of  Vertebrae 
*Lumbago 
Opisthotonos 
Paralysis  Agitans 
Perinephritis 
Phthisis,  Early 
Lorenz'  sign 

Rheumatism 
esp.  gonorrhoea! 

Rheumatoid  Arthritis 
Sacro-iliac     Affections     in- 
cluding '  Relaxation ' 
Senile  Cyphosis 
Spinal  Tumour 
Spondylose  Rhizomelique 
*Sprain 
'  Typhoid  Spine ' 

***  Also  some  laborious  occupa- 
tions. 

807.  Lumbar  Prominence 

Abscess,  Perinephric 

„        Spinal 
Aneurysm,  Abdominal 

„  Renal 

Cancer  of  Colon 
Emphysema,  Interstitial 
*Extra vacation  of  Urine 
Hydatids  of  Kidney 

,,        of  Liver 
*Hydronephrosis 

Kidney,  Rupture  of 
*(Edema  (335) 
Perinephric  Haemorrhage 
v  traumatic 

Perinephritis 
Pyonephrosis 
Renal  Cancer 


BACK   AND  SPINE 

Renal  Sarcoma 
Sarcoma,  Retroperitoneal 

808.  OZdema,  Lumbar 

*  Anasarca  (335) 
Landouzy-Dejerine  Paralysis 
Perinephritis 

Purulent  Spinal  Pachymen- 
ingitis 
livid  swelling 

809.  Scapula  Prominent 
Aneurysm  of  Arch 

left  scapula 

*Lateral  Curvature  (814) 
*Pterygoid  Chest  (741) 
Serratus  Palsy 

810.  Swellings  on  Back 
Bursitis,  Spinal 

of      7th      cervical  —  from 
weights 

*  Carbuncle 

often  diabetic 

Caries  of  Spine 

Dislocation  of  Spine 

Fracture  of  Spine 
*Lipoma 

Sacro-iliac  Disease 
*Sebaceous  Cyst 

Spina  Bifida 

Spinal  Abscess 

Spondylitis,  Traumatic 
dorso  -lumbar 

811.  Rigidity  of  Erector  Spinae 

(Ramond'sSign) 

Pleurisy  with  Effusion 

relaxing  when  fluid  becomes 
purulent 

806-811 


SPIN  E 


243 


CURVATURES   OF  THE  SPINE 

If  friction  is  made  «»vor  the  spine,  the  position  of  the  processes 
will  be  indicated  by  a  beaded  line. 


812.  Anterior  (Cyphosis) 

Acromegaly 

Adenoids  (slight) 

Bronchitis  (x) 
*Emphyscma 

Friedreich's  Disease 

Idiocy 

Mollities  Ossium 

Multiple  Myoma 

Occupation  : 
Cyclists 
Gardeners 
Porters 
Shoemakers 
Tailors 

Osteitis  Deformans 

Paralysis,  General 

Paraplegia.  Congen.  Spastic 

Poliomyelitis,  Anterior 

Progressive  Muscular  Atro- 
phy 

Rachitis  Adolescentium 
*Rheumatism 

Rheumatoid  Arthritis 

Rickets 
it  disappears  when  the  child 
is  lifted  by  its  arms 

Senility 

Spondylitis,  Traumatic 
Spondylose  Rhizomelicuie 
*S\  ringomyelia 

813.  Posterior  (Lordosis) 
*Abdominal  Tumours 

Achondroplasia 
*Ascites 

Cerebro-spinal  Meningitis 


n  2 


Congenital     Dislocation     of 
both  Hips 

Coxa  vara,  Double 

Cretinism 

Idiopathic   Muscular    Atro- 
phy 

Osteitis  Deformans 

Perinephritis 

Poliomyelitis,  Anterior 

Postural  Albuminuria 
*Pregnancy 

Progressive  Muscular  Atro- 
phy (x) 

Pseudo  hypertrophic    Para- 
lysis 

Rheumatism 
Rheumatoid  Arthritis 
Spastic  Paraplegia  (x) 
Syringomyelia 

814.  Lateral  (Scoliosis) 
Ansemia 

Back-Muscles,  Weak 
Caries,  Vertebral 

when  one-sided 
Cervical  Rib 
Coxa  Vara 

unilateral 
Contraction  of  one  Luns 

from  Cirrhosis,  Old  Pleurisy, 

etc. 

Diphtheritic  Paralysis 
Friedreich's  Disease 
*Hip  Disease 
Hysteria 
Infantile  Paralysis 

812-814 


244 


SPINE 


Lateral  (Scoliosis) — could. 
Leg,  One  Short 
Mollities  Ossium 
Neuritis,  Peripheral 
Perinephric  Abscess 

towards  affected  side 
Rickets 

Sacro-iliac  Disease 
Sciatica,  Old 

SprengePs    Scapular   Defor- 
mity 
Syringomyelia 

dorso-lumbar  region,  con- 
vexty  to  left 

Torticollis 

In  children  and  adolescents 
it  is  often  caused  by  the 
exclusive  use  of  one  arm 
for  carrying  (e.g.  a  baby). 


815.  Angular  Curvature 
Aneurysm  of  Desc.  Aorta 

*Caries  of  Spine 

Cancer,  Vertebral 

Hydatids  of  Vertebrae 

Mollities  Ossium 

Sarcoma,  Vertebral 

***  Spina   bifida    may    deceive 
the  tyro. 

816.  Entassement  Vertebrale 

Even  collapse  of  the  bodies 
of  the  vertebrae. 
Malignant    Disease    of    the 
Spine 


817.  Rotary  Twist 

Disease^of    Cerebellar  Ped- 
uncles 

The  twist  is  also  commonly 
associated  with  lateral 
curvature. 


814-817 


ABDOMEN 


24,") 


818.  INSPECTION   OF  THE   ABDOMEN 

The  abdomen  is  divided  into  the  following  regions  :  epigastric, 
right  and  left  hypochondriac,  umbilical,  right  and  left  lumbar, 
hypogastric,  and  right  and  left  iliac.  The  two  vertical  lines  dividing 
these  spaces  are  drawn  upwards  from  the  middle  of  each  Poupart's 
Ligament  respectively ;  the  two  horizontal  lines  connect  the  tips  of 
the  tenth  costal  cartilages  and  the  crests  of  the  ilia.     (See  737.) 


819.  Prominent  Abdomen 

Abdominal  Tumours  (1615) 
Achondroplasia 
Amyloid  Disease 
Appendicitis 

Larvata 
*  Ascites 

smooth  with  dependent 
bulging ;  maximum  cir- 
cumference at  level  of 
navel 

Cirrhosis,  Hypertrophic 

Cceliac  Disease 

Colloid  Omentum 

Colon,  Idiopathic  Dilatation 

of 
Congenital    Dislocation     of 

Hips 

Cretinism 

Dilatation  of  Stomach 

towards  umbilicus  and  left 
side 

Distended  Bladder 

sometimes  enormous  in 
women 

Enteric  Fever 
*Enteroptosis 

'  pendulous  belly  ' 

Fatty  Omentum 
*Flatus 
Gall  Bladder,  Distended 

sometimes  enormous 
Hydatids,  Large 


Hydronephrosis 
Intestinal  Obstruction 

,,  Paralysis 

Intussusception 
Irritant-poisoning 
Kidney,  Large  Cystic 
Leukaemia,  Splenic 
Meteorism 

Mongolian  Imbecility 
Ovarian  Disease 

maximum  girth  below  nave  1 
Pancreatic  Disease 
Paralysis      of      Abdominal 

Walls 
Peritonitis 

esp.  tuberculous  form 

Phantom  Tumour 
disappears     under     chloro- 
form 

Pneurnoperitonaeum 
Pregnancy 

Pseudo  -hypertrophic     Para- 
lysis 
Retention  of  Menses 
*Rickets 

Splenomegaly,  Gross 
Syphilitic  Liver 
Tabes  Mesent erica 
Uterine  Fibroid 

820.  Auenbrugger's  Sign 

A  pulsating  prominence   at 
the  epigastrium. 

Pericardial  Effusion 

818-820 


24G 


ABDOMEN 


821.  Accordion  Abdomen 

Swollen  abdomen  with 
flattening  of  diaphrag- 
matic arch  and  quickened 
breathing.  It  disappears 
under  anaesthesia. 

Nervous  Pseudotympany 

822.  Linese  Albicantesvel  Atro- 
phicse 

Shiny,  bluish  white  de- 
pressed lines  with  minute 
cross  wrinkles.  They 
are  evidence  of  former 
prolonged  skin  stretching 
as   from   pre-existent — 

Ascites 

Cysts,  Ovarian 
Obesity 
Pregnancy 
Tumours,  etc.  (819) 

823.  Retracted     or     Scaphoid 
Abdomen 

Cancer  of  Pylorus 

Cerebro- spinal  Meningitis 

Cholera 

Cyclical  Vomiting 
*Diarrhcea  of  Large  Intestine 
*Lead  Colic 

Meningitis,  Simple 

„         Tuberculous 

Perforation  of  Bowel,  i. 

Peritoneal  Adhesions 

Pyloric  Obstruction 
from  empty  bowel 

Stricture  of  (Esophagus 

Tumours  of  Brain 

Wasting  Diseases  (311) 

824.  Retraction  with  Inspiration 

Asthma,  Spasmodic 
Collapse  of  Lung 
Diphtheritic  Laryngitis 


Toreign   Body  in   Air-pass- 
ages 
Large  Pleural  Effusion 
*Paralysis  of  Diaphragm 

825.  Retraction,  Systolic  Epi- 
gastric 

Pericarditis,  Adhesive 

826.  Recti,  Divarication  of 

This  is  the  result  of  old 
distension.  (See  Linece 
Albicantes,  822) 

827.  Rigidity     of    Abdominal 
Muscles 

Abscess,  Rupture  of 
into  peritonaeum 
*Appendicitis 

right  side.  The  rigidity 
of  appendicitis  is  much 
lessened  when  a  collec- 
tion of  pus  has  formed 

Cancer  of  Liver 

„       of  Uterus 
Colic  (122) 
,,       Lead 

Contusions  of  Abdomen 
Cramps 

Diaphragmatic  Pleurisy 
Enteric  Fever 

adherent  ulcer  or  perfora- 
tion 

*  Gallstone 

right  rectus 
Hsemoperitonaeum 
Hepatic  Abscess 
Hepatitis 

Intestinal  Obstruction  (1078) 
Locomotor  Ataxy 

gastric  crisis 
Perforation     of      Stomach, 
Bowel,  Appendix  or  Gall 

Bladder 

821-827 


ABDOMEN 


247 


Rigidity   of    Abdomin a l 
Muscles — continued 

Pericarditis 
involving  diaphragm 

Peritonitis 

Pneumonia 
in  children 

Ulcer  of  Stomach 
Vesical  Calculus 

lowest  segment  of  rectus 
In  all  forms  of  Colic  and  in 
Locomotor  Ataxy  the 
rigidity  is  paroxysmal 
only. 
When  pre-existing  rigidity 
is  absent  one  rectus  raay 
be  found  hypertrophied. 


828.  Enlarged  Superficial  Veins 

Due  to  venous  obstruction 
internally. 

*  Ascites,  in. 

Carcinoma 
♦Cirrhosis  of  Liver 
Dilatation  of  Stomach 
Liver,    Great    Enlargement 

of 
Mediastinal  Tumours 
Ovarian  Cyst 
♦Portal  Obstruction 

current  upwards 
Sarcoma 

Splenomegaly  ( 1 635 ) 
Thrombosis  of  Iliac  Veins 

current  upwards 
Thrombosis    of   Vena    Cava 

Inferior 

current  upwards 
Thrombosis    of   Vena    Cava 

Superior 

current    downwards 


Tumours,  Abdominal 
,,         of  Liver 


Epigastric  Pulsation  (See  287) 


829.  Visible  Peristalsis 

Right  to  left  =  Intestinal 
obstruction 

Left  to  right  =  Pyloric  ob- 
struction 

Diarrhoea,  Profuse 
Dilatation    of    Colon,    Con- 
genital 
„  of  Stomach 

Divarication  of  Recti 

more  visible  only 
Ileo-csecal  Obstruction 
central  and  ladderlike 

♦Obstruction  in  Colon 

,,     in  Small  Intestine 

Peritonitis,  Old 
Scars,  Stretched 
♦Sigmoid   Obstruction 
course  of  colon 

Stricture   of   Pylorus 

♦*♦  I  have  shown  in  my  work 
on  the  physics  of  the  large 
intestine  that,  owing  to 
the  small  ileo-csecal  aper- 
ture and  the  large  caecum 
there  is  a  real  and  powerful 
hydraulic  pressure  when 
the  large  bowel  is  full. 
The  force  and  obstruction 
combined  will  necessarily 
produce  gyratory  move- 
ments— peristalsis  or  no 
peristalsis.  The  same 
effect  is  seen  when  a 
garden-hose  under  full 
pressure  is  trodden  upon. 

827-829 


248 


ABDOMEN 


THE   NAVEL   OR   UMBILICUS 

The  umbilicus  is  opposite  the  4th  lumbar  vertebra ;  a  point 
slightly  to  its  left,  and  f-inch  below  it,  indicates  the  bifurcation  of 
the  aorta. 


830.  Displaced  Upwards 

Ascites 
Ovarian  Tumour 

and  outwards 
Tuberculous  Peritonitis 

831.  Retracted  Navel 
Obesity 

832.  Stretched  Navel 

Ascites 

Colloid  Omentum 
Ovarian  Tumours 
Pregnancy  till  7th  month 

833.  Fixed  Navel 

Malignant  Disease  of  Liver 
or  Omentum 
sometimes  nodular 

834.  Projecting  Navel 

Abscess 
Ascites  (x) 
Cancer,  Secondary 
colon  or  omentum 


Polypus 

Portal  Obstruction 
Pregnancy  after  7th  Month 
Tuberculous  Peritonitis 
sometimes  red  or  cedematous 

Tumours 

Umbilical  Calculus 
„  Hernia 

835.  Oozing  from  Navel 

Abscess 

purulent 
Congenital  Umbilical  Fistula 

clear 
Meckel's  Diverticulum 

if  patent  throughout,  fsecal 
Peritonitis,  Tuberculous 

purulent  or  fsecal 

Urachus,  Patent 
urinary 

836.  Caput  Medusae 

Enlarged  veins  about  navel 
— rare 
Portal   Obstruction 


830-836 


ABDOMEN 


249 


837.  Enlarged    Glands    in   the 
Groin 

Those  above  Poupart's 
Ligament  draw  their 
lymphatic  vessels  from 
the  perinseum,  external 
genitals,  lower  half  of 
abdomen,  loin,  and  inner 
side  of  the  buttock. 
Those  around  the  saphe- 
nous opening,  from  the 
lower  limb  and  the  outer 
side  of  the  buttock. 

In  general,  irritation  within 
the  above  area,  or  sys- 
temic conditions. 

Abrasions 

Balanitis 

Bites 
♦Blistered  Heel 

Boils 

Burns 

Cancer,  Secondary 

*Chancre,  Hard 

small  and  knotty ;  tj  bi- 
lateral 

Diphtheria 

Ecthyma 

Eczema 

Epithelioma     of    Penis    or 

Anus 
Erysipelas 
Glandular  Fever 
♦Gonorrhoea 
Hooping  Cough 
Intertrigo 
Lymphadenoma 
Measles 
Pediculosis 
Pelvic  Cancer  (x) 
Plague 

second  to  fifth  day 

Prurigo 


Rotheln 

Sarcoma,  Melanotic 

Scarlatina 

Sepsis 
♦Soft  Sore 

large  and  tender  ;  unilateral 

Symmetrical  Adeno-lipoma- 
tosis 

Tuberculosis 

Truss  Irritation 

Varicose  Gland  (filarial) 

Varicella 
♦Wounds,  Inflamed 


838.  Swelling  about  Groin 

Abscess,  Glandular 

„         Iliac 
Abscess,  Psoas 

thigh  drawn  up 

Aneurysm 
of  Ext.  Iliac 

*Bubo 
Carcinoma 
Cysts 

Dislocation  of  Hip 
Glands,  Enlarged 
Hematocele  of  the  Cord 
Hernia,  Femoral 
♦Hernia,  Inguinal 

,,         Obturator 

„         of  Ovary 
Hip  Disease 
Hydrocele  of  the  Sac 
Psoas  Bursitis 
Rider's  Bone 

Testis,  Partially  Descended 
Tumour  of  the  Cord 

„       of  Round  Ligament 
Sarcoma 

837-838 


250 


ABDOMEX 


839.  Swollen  Perinaeum 

Extravasation  of  Blood 
.,  of  Urine 

*Ischio-rectal  Abscess 
Perineal  Abscess 
Prostrate,  Enlarged 
Testis  in  Perimvum 


840.  Perinaeal  Ulcers 
Abscess,  Perinaeal 
„         Prostatic 
Chancre 
Condyloma 
Epithelioma 
Fistula 
Folliculitis 
Gonorrhoea 
in  women 
Prostate,  Tuberculous 
Trauma 


839-840 


LIMBS 


251 


INSPECTION   OF  THE   LIMBS 

841. — To  determine  whether  these  are  of  equal  length, 
fix  one  end  of  a  tape  measure  against  the  anterior  superior 
spine  of  the  ilium,  and  the  other  against  the  tip  of  the  inner 
malleolus.  For  girth,  the  thickest  part  of  the  thigh  and  calf 
respectively  should  be  selected.  The  arm  may  be  measured 
from  the  acromion  process  to  the  base  of  the  styloid  process 
of  the  radius,  the  forearm  being  midway  between  pronation  and 
supination.  Transversely,  the  upper  arm  should  be  measured 
over  the  middle  of  the  biceps,  and  the  forearm  about  one 
inch  below  the  olecranon. 


842.  Swellings  of  Soft  Parts 

Abscess 

Aneurysm 

Carcinoma 

Cyst 

Hasmatoma 

Myoma 

Myositis  Ossificans 

Ruptured  Fascia 

Sarcoma 

Trichinosis 

843.  Swellings  of  Bone 
Achondropla  si  a 

epiphyses 

Acromegaly 
'  Aneurysm  of  bone  ' 
*Cancer,  Secondary 
Cysts 

Enchondroma 
Epiphysitis,  Acute 
Erectile  Tumours 
Exostosis 
Fibroma  (x) 
Gummata 
Hydatids  (x) 
Infantile  Scurvy 
Leontiasis  Ossea 


Multiple  Myoma 

Myelo-sarcoma 

Osteitis 

,,       Deformans 
Osteo-arthritis 
Osteomyelitis 
Periostitis 

„  Syphilitic 

circumscribed 
Pulmonary  Osteoarthro- 
pathy 
*Rheumatoid  Arthritis 
*Rickets 
epiphyses 
Sarcoma,  Periosteal 
Schlatter's  Disease 
Scurvy 

Syphilis.  Congenital 
Tubercle 

Stiffness 

(See  Joints,  915) 

844.  Crepitus 

Fractures 

Synovitis  and  teno-synovitis 
give  a  quasi-crepitant 
feel ;  osteo-sarcoma  of 
the  long  bones,  an  '  egg- 
shell crackling.' 

841-844 


252 


LIMBS 


845.  Nodes 
Enteric  Fever 
Erythema  nodosum 

*Exostosis 
Scurvy 
*Syphilis 

846.  Subcutaneous  Nodules 

Adiposis  Dolorosa 

Chorea 

Gout 

Ganglion 

over  tendon 
Periarteritis  Nodosa 

over  an  artery 
*Rheumatism  in  System 

if  near  a  joint 
Rheumatoid  Arthritis 

near  joints 
Trigger  Finger 

847.  Fragilitas  Ossium 

(Brittle  Bones) 

Blue  Sclerotic  (475) 

Cancerous  Cachexia 

Carcinoma  of  Bone 

Caries 

Chloroma 
*Disseminated  Sclerosis 

Disuse,  Prolonged 

Friedreich's  Disease 
*  General  Paralysis 

Hemiplegia 

Hydrocephalus 

Infantile  Paralysis 
„        Scurvy 

Insanity 

Lateral      Sclerosis,     Amyo- 
trophic 
*Locomotor  Ataxy 


Multiple  Myoma 
Myelo -sarcoma 
Osteogenesis  Imperfecta 
Osteomalacia 
Phosphorus-poisoning 
Rickets 
Scurvy 
Senility 
Syphilis 
*Syringomyelia 

In  '  Essential  Fragilitas 
Ossium,'  the  repeated 
fractures  of  childhood 
cease  about  puberty. 

848.  Trochanter     Displaced 
above  Nelaton's  Line 

Congenital  Hip  Dislocation 
Coxa  vara 
*Dislocation  on   Dorsum  Ilii 
Fracture  of  Neck  of  Femur 

extra  capsular 

Nelaton's  line  is  one  drawn 
between  the  anterior 
superior  spine  and  the 
tuber  ischii. 

849.  Allis*   Sign 

The  fascia  lata  between  the 
crest  of  the  ilium  and  the 
trochanter  major  is  re- 
laxed. 

Fracture  of  Neck  of  Femur 

850.  Scarpa's  Triangle,  Swell- 
ings in 

Abscess,  Psoas 
Bursa,  Sub -psoas 
Glands,  Cancerous 

„  Inflamed 

„  Tuberculous 

Hernia,  Femoral 

845-850 


LIMBS 


253 


Scarpa's   Triangle,    Swell- 
ings in — continued 
Hernia,  Obturator 
behind  adductor  longus 

Testis,  Ectopic 
Tumours 

fibroma,  lipoma,  sarcoma 
Varix,  Saphenous 

851.  Leg  Lengthened 

Dislocation    of    Hip    down- 
wards 
Hip  Disease,  i.  (?) 
Hip  Disease,  Hysterical 
Putnam's  Sign 
*Sacro-iliac  Disease 


854.  Leg  Curved 
Achondroplasia 

Cretinism 
Fracture 
Mollities  Ossium 

distorted 
Osteitis  Deformans 
Osteogenesis  Imperfecta 
Osteomalacia 
Osteomyelitis,  Old 
*Rickets 

exaggerated  normal  curve 
Syphilis,  Hereditary 

'  sabre-blade  shin ' 

One  leg  is  apt  to  become 
curved  when  the  other 
is   shortened. 


852.  Leg  Shortened 

The  surgical  condition  may 
be  old. 

Achondroplasia 

Coxa  vara 

Cretinism 

Congenital    Dislocation     of 

Hip  upwards 
Dislocation  of  Hip  upwards 
*Fractured  Femur 
neck  or  shaft 
Fracture  of  Tibia 
*Hip  Disease 
Infantile  Hemiplegia,  Old 

„        Paralysis,  Old 
Osteomyelitis,  Old 

853.  False  Shortening 

Obliquity  of  pelvis. 

*Hysteria 
Lateral  Curvature 
Pelvic  Cellulitis      \ 


855.  Seissor-Legs   or   Crossed- 
Leg  Deformity 
Ankylosis    in    Double    Hip 

Disease 
*Double  Coxa  vara 
Spastic  Cerebral  Paraplegia 


856.     Heilbronner's 
Bein 


Breites 


Apparent  broadening  of 
the  thigh  depending  upon 
hypotonia  of  the  para- 
lysed muscles  when  the 
patient's  limb  is  on  the 
mattress. 

(Not  present  in  functional 
paralysis.) 


857.  Feet  Enlarged 

♦Acromegaly 

Pulmonary     Osteo- arthro- 
pathy 
(See  (Edema,- 864.)    - 

850-857 


254 


LIMBS 


858.  Pes   Areuatus   vel  Cavus 
(Claw    Foot) 

Chorea  (x) 
♦Friedreich's  Disease 

the  foot  cannot  be  dorsally 
flexed  beyond  a  right 
angle 

Infantile  Paralysis  (x) 
it  unilateral 

Paralysis,  Int.  Popliteal 
Pseudo-hypertrophic    Para- 
lysis (x) 
Spastic  Paraplegia 
Syringomyelia 
Talipes  equino-varus 

„      equinus 
Tetany 

859.  Foot  Everted 
Coxa  vara 

♦Fracture,  Pott's 
♦Fracture  of  Neck  of  Femur 
more   everted  when   extra- 
capsular 

Fracture  of  Tibia  and  Fibula 
Hip,  Dislocation  into  Fora- 
men 
,,  on   Pubes 

Infantile  Paralysis 
Locomotor  Ataxy 
Peronaeus,  Slipped 
Rickets 

Spastic  Paralysis 
Talipes  valgus 

860.  Foot  Turned-in 

Fracture  of  Neck  of  Femur 

(x) 
*Hip,  Dislocation  on  Dorsum 

Ilii 
Locomotor  Ataxy 


Pseudo-hypertrophic    i'a  i  a  - 

lysis 
Slipped  Tibialis 
Spastic  Paraplegia 
Talipes  varus 

anterior  half 
Tooth's  Paralysis 


861.  Toe  Swollen 

Abscess 
♦Bunion 

Bursitis 

Cellulitis 
♦Chilblains 

Erysipelas 
♦Gout 

Mycetoma 
♦Rheumatoid  Arthritis 


862.  Popliteal  Swellings 

The  glands  receive  the  deep 
lymphatics  of  the  leg, 
knee,  and  foot.  No  lym- 
phatic glands  are  found 
below  this  space. 

Abscess 

under  fascia 

♦Aneurysm 
Bursae 

that  under  the  semi-mem - 
branosus  communicates 
with  the  knee-joint 

Cyst,  Baker's 
Enlarged  Glands 
Epiphysis,  Separated 
Exostosis,  Cancellous 
Lipoma 
Myelo-sarcoma 
Periostitis 
Sarcoma,  Periosteal 

858-862 


LIMBS 


255 


863.  (Edema  of  One  Foot  and 

Leg 

When  one  leg  is  swollen 
the  cause  is  usually  local ; 
when  both,  constitutional. 

Aneurysm,  Femoral 
,,  Popliteal 

♦Cellulitis 

Dissecting  Aneurysm 

Erysipelas 

Erythema  Nodosum 

Gout 

Kidney,  Cancer  of 

Milroy's  Disease 

Mycetoma 

Osteomyelitis 

Periostitis 
♦Phlebitis 

Phlegmasia  Alba  Dolehs 
u  left  leg 

Stings 
Thrombosis 
♦Varicose  Veins 
deep  or  superficial 
♦*♦  Tight   garters   or   bandages 
will  cause  it. 

864.  (Edema  of  Both  Feet 

Acute  Ascending  Paralysis 
♦Abdominal    Tumours 

Anaemia 
♦Anasarca  (335) 

Aneurysm,  Abdominal 

Ankylostomiasis 

Beri-beri  (shins) 

Bothriocephalism 

Cachexia 

Cceliac  Disease 

Chlorosis 
♦Cirrhosis  of  Kidney 
of  Lung 

Dilatation  of  Heart 


Emphysema 

Essential    Dropsy    of    Chil- 
dren 

Exophthalmic  Goitre 

Fatty  Degeneration  of  Heart 
(x) 

Haemorrhage,  Profuse 

Leukaemia 

A'enorrhagia 

Milroy's  Disease 
sharply  demarcated 
♦Mitral  Disease 

Myxcedema 

Xephritis 

Ovarian  Cyst 

Peritonitis,  Chronic 

Pernicious  Anaemia 

Phthisis,  ii. 

Pregnancy 

Pseudo-leukaemia  Infantum 

Retroperitoneal  Sarcoma 

Scurvy 

Splenic  Anaemia 

Thrombosis  of  V-  Cava 

Trichinosis 

Trypanosomiasis 

Tuberculosis 

Urticaria 
♦#♦  Excess  of  salt  in  the  food 
will  produce  oedema.  It 
is  common  in  conva- 
lescents upon  first  getting 
up. 
(See  Anasarca,  335) 

865.  Varicose  Veins 

Aneurysm,  Abdominal 
♦  Pregnancy 

Sigmoid,  Loaded 
♦Standing  Occupations 

Thrombosis 

Tumours,  Abdominal 
„  Pelvic 

863-865 


256 


LIMBS 


866.  Perforating  Ulcer  of  Foot 

Diabetes 

General  Paralysis 
Leprosy 
*Locomotor  Ataxy 
Peripheral  Neuritis 
Syphilis 
Syringomyelia 

867.  Hallux  Erectus 

Hyperextension  of  great  toe. 

Flexor  Tendon,  Severed 
♦Friedreich's  Disease 

868.  Gangrene  and  Phalangeal 

Necrosis 

Gangrene  is  dry  when  due 
to  blocked  arteries  alone  ; 
moist,  when  the  veins  or 
both  veins  and  arteries 
are  blocked. 

Anthrax 
*Arterio-sclerosis 

Arteritis1,  Obliterative 

Beri-beri 

Burns 
*Diabetes 

Embolism 
*Ergotism 

Exophthalmic  Goitre 

Frostbite 

Glanders 

Hysteria 

Injuries 

Leprosy 
*Morvan's  Disease 

painless  whitlows,  etc. 

Neurasthenia 

Plague 

♦Raynaud's  Disease 
symmetrical 


♦Senility 

Snake-poison 
Syringomyelia 
Thrombosis 
Wounds,  Crushed 

Tight   bandages   or    splints 
may    produce    gangrene. 


869.  Pad  on  Dorsum 

Yellow-wax-like 

Rickets 


870.  Cold  Extremities 

*Ague  (cold  stage) 
♦Anaemia 

Aneurysm 

Arterio-sclerosis 

Arteritis 

Cholera 

Collapse  (235) 

Concussion  of  Brain 

Cyanosis  (396) 
♦Dilatation  of  Heart 

Ergotism 

Frostbite 

Gangrene,  Senile 

Hypothyroidism 

Intestinal  Stasis 

Locomotor  Ataxy 

Malformation  of  Heart 

Mitral  Disease 

Neurasthenia 

Paralysis 
*Raynaud's  Disease 

Stomach,  Atony  of 

Syringomyelia 

affected  limb 

Tooth's  Paralysis 

866-870 


LIMBS 


257 


871.  Digiti  Mortui 

'  Dead  fingers.' 

Arthritis,  Rheumatoid 
praemon. 

Cardiac  Disease 
Hsemoglobinuria,     Paroxys- 
Locomotor  Ataxy  [mal 

Nephritis,  Chronic 
Sclerodermia 

872.  (Edema  of  Arm 

The  arms  of  stout  women 
near  the  menopause  fre- 
quently become  cedema- 
tous  without  organic 
cause.  Sometimes  the 
dress  compresses  the  ax- 
illary veins. 

Aneurysm  of  Aorta 
transverse 

Aneurysm  of  Axillary 
,,  of  Innominate 

♦Cellulitis 
*  Erysipelas 
Glands,  Enlarged  Axillary 
Hysterical  (Edema 
(hands — not  pitting) 

Mediastinal  Tumour 

Mediastinitis 

Mycetoma 

Myositis 
*Stings 

Thrombosis 

Trichinosis 
♦Urticaria 

(See  Anasarca,  335) 

873.  Axillary  Swellings 

♦Abscess 

,,  Tuberculous 

Accessory  Mammae 


Adeno-lipomatosis 
♦Affections  of  Glands 

Aneurysm 

Hygroma,  Cystic 
♦Lipoma 
♦Sebaceous  Cyst 

874.  Enlarged  Axillary  Glands 

The  pectoral  chain  of  glands 
receives  its  lymphatic 
vessels  from  the  mamma 
and  the  front  of  the 
chest ;  the  subscapular 
group  from  the  back; 
and  the  central  series 
from  the  arm,  hands, 
thumb,  and  index  finger. 
They  swell  from  local  irri- 
tation in  the  above  areas 
or  from  systemic  condi- 
tions. 

Acute  Infectious  Diseases 

Blister,  Inflamed 

Boils 

Cancer  of  Breast,  n. 
„       of  Bone 

Diphtheria 

Ecthyma 

Erysipelas 

Glandular  Fever 

Hangnail,  Septic 

Hooping  Cough 

Leukaemia 
♦Lymphadenoma 

Lymphosarcoma 

Measles,  I. 

Parotitis 

Plague,  Bubonic  (x) 

Rotheln 

Sarcoma,  Secondary 

Scarlatina 
♦Sepsis 

Symmetrical  Adeno  lipoma- 
tosis 

871-874 


258 


LIMBS 


Axillary  Glands — continued 
Syphilis 
Varicella 
*Wound,  Inflamed 

***  Those  secondary  to  cancer 
of     the     breast 


occasionally 
opposite  axilla. 


appear 
in        the 


875.  Shoulder  Swellings 

♦Bursa,  Enlarged 
Cancer 
Dislocations 
Fracture  of  Acromion 
„        of  Clavicle 
„         of    Neck    of    Hu- 
merus 
Separated  Epiphysis 
♦Synovitis 
Tumours 

876.  One  Shoulder  Raised 

Cirrhosis  of  one  Lung 
♦Lateral  Curvature  (814) 

Pleurisy,  Old 

Sacro-iliac  Disease 
♦Sprengel's  Deformity 

Syringomyelia 

877.  Enlarged     Epitrochlear 

Gland 

The  lymphatics  come  from 
the  forearm,  hand,  and 
three  inner  fingers.  No 
lymphatic  glands  are 
found  in  the  forearm 
below  this. 


Chancre,  Digital 
Hereditary  Syphilis 
Rheumatoid  Arthritis 
Still's  Disease 
Whitlow 

878.  Gaertner's    Vein    Pheno- 
menon 

The  veins  of  the  arm  are 
watched  when  the  arm  is 
raised  to  different  angles. 
The  result  is  said  to  be  a 
guide  to  the  pressure  in 
the  right  auricle  and  con- 
sequently to  the  degree 
of  compensation  present. 

879.  Ulnar  Nodes 

Erythema  Nodosum 
Gummata 


880.  *  Silver  Fork  Wrist ' 

So  called  from  the  curve. 

Colles's  Fracture 

Dislocation  of  Wrist 

***  Chauffeur's      Fracture      is 
higher    up    than  Colles's. 

881.  Arm  Shortened 

Achondroplasia 
Dislocation  Upwards 
Fracture  of  Humerus 
with  displacement 

Infantile  Hemiplegia 
„         Paralysis 


874-881 


THE  HANDS 


259 


THE  HANDS 


882.  Manus    Valga    or    Made- 
lung's  Deformity 

The  radius  is  bowed  out- 
wards and  the  hand 
adducted.  It  is  due  to 
irregularity  of  growth  at 
the  lower  radial  epiphysis. 

Central  Nervous  Disease 

Rickets 

Trauma 

883.  Seal-Fin  Deformity 

The  hand  is  deflected  ulnar  - 
wards 

Osteo -Arthritis 
Rheumatoid  Arthritis 

884.  Hand  Enlarged 

Acromegaly 

Pulmonary    Osteo -arthro- 
pathy 

Syringomyelia  (x) 
cheiromegaly 

885.  Swollen  Hand 
'  Beat  Hand  ' 
Cellulitis 
Erysipelas 
Gout 

Hysterical  (Edema 
Mycetoma 
Stings 
Thrombosis 
Trichinosis 

(See  (Edema,  335) 

886.  Spade  Hand 

Cretinism 

Mongolian  Imbecility 
Myxoedema 


887.  Claw     Hand     (Main-en- 
grifle) 
The     first     phalanges     are 
over-extended,  the  others 
over-flexed. 

Amyotrophic  Lateral    Scle- 
rosis 
*Eriedreich's  Disease 

or  '  main  bote  ' — over-ex- 
tended terminal  phalanges 

Pachymeningitis,  Cervical 
Poliomyelitis,  Anterior 
adults 

Progressive  Muscular  Atro- 
phy 
Rib,  Cervical 

Syringomyelia 

S.  '  succulent  hand  ' 
*Tetany 

Tooth's  Paralysis 
*  Ulnar  Paralysis 

Dupuytren's  disease  simu- 
lates this,  but  is  dis- 
tinguished by  the  palmar 
fascia  being  contracted. 

888.  Ape  Hand 

Claw  hand  plus  inability  to 
oppose  the  thumb. 

Median  Nerve  Paralysis 
Progressive  Muscular  Atro- 
phy 

889.  Preacher's  Hand 

Claw  hand  plus  hyper- 
extension  of  the  wrist. 

Pachymeningitis,  Cervical 

The  wrist  is  hyper-extended 
in  Progressive  Muscular 
Atrophy. 

2  882-889 


260 


THE  HANDS 


890.  Accoucheur's   Hand 

A   conical    arrangement    of 
the    fingers. 

Athetosis 
Cramps  (x) 
Tetany 

(See    Trousseau's     Pheno- 
menon, 1432) 


891.  Dupuytren's    Contraction 

The  first  and  second 
phalanges  are  flexed,  the 
third  extended.  A  dense 
ridge  passes  from  the 
palmar  fascia  to  the  bent 
fingers. 

Diabetes 

Gout 

Neurosis 

It  is  found  in  gardeners, 
sculptors,  carvers,  and 
others  who  are  subject  to 
palm  pressure. 


892.  Heberden's  Nodes 

A  knobby  enlargement  of 
the  terminal  phalanges 
at  their  proximal  extremi- 
ties. They  are  specially 
liable  to  appear  at  the 
menopause,  and  are  often 
merely  signs  of  hard 
manual  labour. 

Gout 

Osteo-arthritis 
Toxaemia,  Intestinal 


893.  Haygarth's  Nodes 

The  enlargement  is  fibrous 
only. 

Rheumatism,  Chronic 


894.  Koplik's  Stigma    of  De- 
generation 

Prominence    over    pisiform 
bone 

Cretinism,  Sporadic 
Wrist  Drop.    (See  1323) 

895.  Clubbed     or    Drum-stick 
Fingers 

Digitus  Hippocraticus. 

Aneurysm     of     Aorta     (x) 
or  Axillary  Artery 
unilateral 

Banti's  Disease 
Cirrhosis,  Hanot's 
of  Lung 
Dyspnoea,  Chronic  (1223) 
Emphysema 
Empyema 
may  disappear  after   para- 
centesis 
Fibroid  Lung 
Malformation  of  Heart 
*Phthisis,  i. 
Pleurisy,  Old 

Pulmonary     Osteo     arthro- 
pathy 

896.  Camptodactylia 

A  fixed  painless  flexion  of 
the  middle  and  terminal 
phalanges  of  the  4th  and 
5th  fingers,  the  palmar 
fascia  being  unaffected. 

Arthritism,  Early 

897.  *  Camptodactylia,  Limited' 

Extension  of  ring  and  little 
fingers 

Tuberculosis,  Pulmonary 

890-897 


THE  HANDS 


261 


898.  Fingers  Bent 

Achondroplasia 

two  inner  fingers  inwards, 
two  outer  fingers  out- 
wards ('Trident  Hand') 

Cervical  Rib 

Paralysis,  Ischsemic 
Mongolian  Imbecility 
little  finger  curved 

Tendon,  Divided  Opposing 

899.  Finger  Swollen 
*Abscess 

Achondroplasia 

and  shortened 
Acromegaly 
broadened 

Cellulitis 
♦Chilblains 

Dactylitis,  Syphilitic 

Erysipelas 

Foreign  Body 
♦Gout 

Pulmonary      Osteo-  arthro- 
pathy 

shafts  ^of  long  bones 
thickened 


♦Rheumatoid  Arthritis 
spindle-shaped  joints 

Sclerodactylia 
Syphilitic  Dactylitis 
Tubercle  of  bone 

spina  ventosa 


900.  Finger-tips     Red     and 
Swollen 

♦Chilblains 

Erythromclalgia 

Hysteria 

Locomotor  Ataxy 

Lupus  Erythematosus 

Neurasthenia 
♦Onychia 

Whitlow 


901.  Garrod's  Finger  Pads 

Swelling  the  size  of  a  split 
pea  on  interphalangeal 
knuckles. 

Dupuytren's  Contraction 
early  or  prsemon.  stage 
Osteo-arthritis 


898-901 


262 


THE  NAILS 


902.  THE  NAILS 

The  finger  nails  take  about  six  months  to  grow,  the  toe  nails 
about  eighteen  months. 


903.  Cyanosed 

*Ague  (cold  stage) 

Dyspnoea  (1223) 

Emphysema 
♦Malformation  of  Heart 

Mitral  Disease 

Phthisis 

Raynaud's  Disease 

Syringomyelia 

Xerodermia  pigmentosum 
(See  Cyanosis,  396) 


904.  Brittle  (Onychorrhexis) 

Chancre,  Primary 
Cheiropompholyx 
Eozema 

surface  pitted 

Exophthalmic  Goitre 

Favus 

Gout 

Hyperidrosis 

'  egg-shell '  nail 

Leprosy 
*Neuritis 
Onychomycosis 
Pellagra 

Pulmonary  Osteo  arthro- 
pathy 
Psoriasis 

Raynaud's  Disease 
Rheumatoid  Arthritis 
Sclerodermia 
Syphilis 
Syringomyelia 


905.  Nails  Shed 

A    common     cause    is     de- 
squamation. 

Alopecia  Universalis 

Diabetes 

Enteric  Fever 

Epidermolysis  Bullosa 

Gonorrhoea  (x) 
*Injury 

Leprosy 

Locomotor  Ataxy 

Morvan's  Disease 

Onychia 

Pemphigus  Foliaceus 

Pityriasis  Rubra 
♦Psoriasis 

Ringworm,  Ungual 

Scarlatina 
♦Syphilis 

Whitlow 

906.  Incurved  Nails 

Diabetes  and  other  Wasting 
Diseases 

907.  Grooved  Nails 
Alopecia 

Arsenic  -poisoning 

or  a  white  transverse  line 

♦Eczema 
Exophthalmic  Goitre 
Gout 
Insanity 
Leprosy 
Neurasthenia 
Neuritis 

902-907 


THE  NAILS 


263 


Grooved  Nails — continued 
Pemphigus  Foliaceus 
Pityriasis  Rubra 
Psoriasis 

Pulmonary       Osteo-  arthro- 
pathy 
Whitlow,  Old 

%*  Transverse  lines,  indicative 
of  a  recent  illness,  are 
known  as  Beau's  Lines. 


908.  Enlarged   and   Thickened 
Nails 

Acromegaly 
Hyperidrosis 
Ichthyosis 
♦Keratosis 
Onychogryphosis 

horn-like 
Pemphigus  Foliaceus 
Pityriasis  Rubra 
Psoriasis 

Ringworm,  Ungual 
Scleronychia 
Syringomyelia 


909.  Ulcers  around  Nails 
Chloral  Habit 
Ingrowing  Toe  Nail 
Injuries 

*Syphilis,  Primary 
„         Tertiary 
Trauma 
Tuberculosis 

910.  Koilonychia 

'  Spoon  nails.' 

Acute  Wasting 

Eczema 

Scurvy 

Senile  Decay 

Subungual  Haemorrhage 

911.  '  Reedy  '  Nails 
Arsenic-poisoning 

*Gout 
Irritation,  Local 
Nail  Biting 
Raynaud's  Disease 

912.  Quincke's  Sign 

Rhythmic  reddening  and 
blanching  of  the  finger 
nails. 

Aortic  Regurgitation 


908-912 


264 


THE   JOINTS 


913.  THE  JOINTS) 

When  much  fluid  is  present,  crepitation  is  replaced  by  fluctuation, 
and  this  disappears  when  the  tension  is  very  great.  To  feel  crepita- 
tion, the  joint  should  be  grasped  while  the  patient  extends  and 
flexes  it. 


914.  Swollen 

Achondroplasia 
relative 

Antitoxin  (x) 
Beat  Knee 

below  patella 
Cerebro -spinal  Meningitis 
*Charcot's  Joint 

esp.  knee — painless 
Cyst,  Morrant  Baker's 

circumscribed  swelling 

Dengue 
Diphtheria  (x) 
Dysentery 
Fracture  into  Joint 
Gonorrhceal  Arthritis 
often  monarticular 

Glanders 
Gout 

great  toe 

Haemophilia 

sudden  onset 

Hereditary  Syphilis 
Hydrops  Articuli 
Hysterical  Joint 
Infantile  Scurvy 
about  large  joints 

Influenza  (x) 

Intermittent   Hydrarthrosis 
Locomotor  Ataxy 
Charcot's  Joint 

Loose  Cartilage 
intermittent 


Malta  Fever 

Osteitis,  Acute  Articular 

Osteo -arthritis 

irregular  bony  growths 
Osteomyelitis  Acute  (x) 
Peliosis  Rheumatica 
Pneumococcal  Arthritis 

monarticular 

Puerperal  Fever 
Pulmonary        Osteo-arthro- 

pathy 
Purpura  Hsemorrhagica 

,,        Henoch's 
Pyaemia 
*Rheumatism,  Acute 

wandering 
Rheumatoid  Arthritis 

fusiform 
Scarlatinal  Arthritis 
Scurvy 
Septic  Arthritis 

not  wandering 

*Synovitis,  Acute 

„         Tuberculous 

boggy  swelling 
Syphilis,  Congenital 

separated  epiphyses,  etc. 
Syphilitic  Arthritis 

monarticular 
Syringomyelia 

upper  limbs 
Trichinosis 

913-914 


THE  JOINTS 


265 


Swollen — continued 

Uraemia  (x) 

Typhoid  Arthritis 

Variola  (x) 
*%*  Exclude  bursse. 

915.  Stiff  Joints 

Abscess  near  Joint 
♦Adhesions 
Appendicitis 

right     abdominal     muscles 
and  hip 

Ankylosis 

Antitoxin  (x) 

Arthritis  Ossificans 
Jf,,         Pneumococcal 

1  Beat  Knee  '  or  '  Elbow  ' 

Cancer 

Caries  of  Spine 

Displaced  Cartilages 
joint  may  lock 

Disuse 
♦Fibrositis 

Gonorrhceal  Arthritis 
*Gout 

Hysterical  Joint 

Injuries 

Lichen  ruber 

Myositis   Ossificans 
♦Pelvic  Cellulitis 
one  thigh 

Perinephritis 

Peritonitis 

Phlebitis 

Polymyositis 

Pulmonary       Osteo- arthro- 
pathy 
*Rheumatism 
♦Rheumatoid  Arthritis 
moderate 

Sclerodermia 


Spondylose  Rhizomelique 
spine,  shoulder,  and  hip  i 
Synovitis,  Simple  or  Tuber- 
culous 
Syphilitic  Arthritis 
♦Synovial  Effusion 
Trichinosis 
Tuberculous  Joint 
Ulceration  of  Cartilage 
***  Rigidity  must  not  be  mis- 
taken   for    stiffness    (see 
1406) 

916.  Creaking  Joints 

Charcot's  Joint 
Morvan's  Disease 
Myxcedema 
Osteitis  Deformans 
Osteo-arthritis 
marked  grating  (1802) 

Rheumatism 
Rheumatoid  Arthritis 
Synovitis,  i.  and  m. 

'  snow  crunching ' 

917.  Distorted    or    Contracted 
Joints 

Caries  of  Epiphysis 
Coxa  vara 
Dislocation 
Epiphysis,  Separated 
Fracture 
Genu  retrorsum 

,,     valgum 

,,     varum 
Locomotor  Ataxy 
Osteitis  Deformans 
Osteo-arthritis 

marked 
Rachitis  Adolescentium 
Rheumatoid  Arthritis 

moderate 
Rickets 

914-917 


266 


THE   JOINTS 


918.  Genu  Retrorsum  (Hyper- 
extension) 

To  detect  this,  the  patient 
should  lie  on  the  back 
while  the  foot  is  raised 
and  supported  and  the 
knee  pressed  down. 

Congenital    Paralytic    Club 

Foot 
Deformity  of  Opposite  Leg 
Infantile  Paralysis 
*Locomotor  Ataxy 
Charcot's  Disease 

Myelitis,  Chronic 

with  atrophy 
Rickets,  Advanced 
Rudimentary  Patella 
Syringomyelia 


919.  Suppurating  Joints 

Arthritis,  Secondary 

„         Septic 

cerebro-spinal meningitis,  pneu- 
monia, scarlatina,  variola 

Gonorrhoea  (x) 
Pysemia 

920.  Tailor's  Rotation 

Coxa  vara 
Absent  in  M.  coxa) 


918-920 


THE  GENITAL  ORGANS 


267 


921.  THE    GENITAL   ORGANS. 


922.  Priapism 

This  may  occur  at  any  age  ; 
a  similar  condition  obtains 
in  the  clitoris. 

Ascarides 

Calculus  of  Bladder 

„         Urethral 
Cantharides-poisoning 
Circumcision 
sequel 

Convalescence    from    Acute 

Disease 
Cord,  Injury  to 

upper  dorsal  segments 

Distended  Bladder 

Epilepsy  (praem.) 
♦Gonorrhoea 

Haemorrhage  in  Middle  Lobe 
of  Cerebellum 

Haemorrhoids 

Hydrophobia 

Lesion  of  Pons 

Leukaemia 
*Loaded  Rectum 

Myelitis 

Oxaluria 

Prostatic  Disease 

Spinal  Meningitis 

Tetanus 

Thrombosis    of    C.     Caver- 
nosum 

Urethritis,  Simple 
Gouty 

Action  of  cantharides , 
camphor,  cannabis  indica, 
damiana,  phosphorus, 
strychnine,  turpentine. 


923.  Penile  Ulceration 
Balanitis 
Chancre,  Hard 

dry,  solitary,  with  indurated 
base ;    long  incubation 

Chancre,  Soft 

multiple,  purulent,soft  base ; 
short  incubation 

Epithelioma 
Gummatous  Ulcer 

yellowish  sloughy  base 
Herpes  Progenitalis 

a  festooned  margin ;  pre- 
ceded by  small  vesicles 

Lupus 

Tuberculous  Ulcer 

shallow,  with  overhanging 
edges 

Varicella 

Variola 

The  two  forms  of  chancre 
may  be  contracted  sim- 
ultaneously and,  further, 
a  hard  sore  may,  by 
becoming  septic,  suppu- 
rate and  so  simulate  a 
soft  sore. 

924.  Urethral  Discharge 

Catarrh 

Chancre  in  Urethra 

Foreign  Body 
♦Gleet 
♦Gonorrhoea 

Gumma  in  Urethra 

Herpes,  Urethral 

Papilloma 

Praeputial  Calculus 

921-924 


268 


THE  GENITAL  ORGANS 


Urethral  Discharge — contd. 
Prostatis 
Tubercle,  Local 
Urethral  Soft  Sore 
Urethritis 

925.  Spermatorrhoea 

Ascarides 

Loaded  Rectum 

Locomotor  Ataxy 

Masturbation 

Myelitis,  Transverse 

Neurasthenia 

Venereal  Excess 

***  Normal     at     intervals     in 
celibates. 

926.  Swelled  Testicle 

Abscess 

Cancer 
*Cystic  Disease 

Enchondroma 
*Epididymitis 

Malta  Fever 
*Orchitis,  Simple 

Orchitis,  Syphilitic 

painless,  ~u  bilateral,  epidid- 
ymis unaffected 

Orchitis,  Tuberculous 
begins  in  epididymis 

Sarcoma 
Torsion  of  Cord 
Tumours 

927.  Impotence 

The  spermatozoa  may  be 
few  (oligospermia),  absent 
(aspermia),  or  motionless 
(necrospermia). 

Amyotrophic    Lateral   Scle- 
rosis 


Ataxic  Paraplegia 
early 

*Atrophy  of  Testes 
Bromism 
Cachexia 

Cord,  Compression  of 
Dementia 
Diabetes 

General  Paralysis 
but  powers  exalted  at  first 

Lead-poisoning 
*Locomotor  Ataxy 
Myelitis,  Transverse 
Neurasthenia 
Pernicious  Anaemia 
Pituitary  Tumour 
eunuchism 

Primary  Spastic  Paraplegia 
Progressive  Muscular  Atro- 
phy 
Seminal  Vesiculitis,  in. 
Senility 

Testicles,  Atrophy  of 
Varicocele  (x) 
Venereal  Excess 

In  another  category  are 
mechanical  impediments 
such  as  elephantiasis,  the 
premature  seminal  emis- 
sions of  nervousness,  etc. 


928.  Pendulous  Testicles 

Debility 
Diabetes 
Impotence  (927) 
Locomotor  Ataxy 
Masturbation 
Sexual  Excess 
Spermatorrhoea 

924-928 


THE  GENITAL  ORGANS 


269 


929.  Scrotal  Swelling 

Abscess,  Urethral 
*  Anasarca  (335) 
Bites  of  Insects 
Cancer,  Encephaloid 
Chancre 
Condyloma 
Cyst,  Sebaceous 
Elephantiasis 
'  lymph  scrotum  ' 

Epithelioma 

('  chimney-sweep's  cancer ') 

Emphysema 

Erysipelas 

Hematocele 

opaque  ;    onset  sudden 

Hernia,  Congenital 
,,        Inguinal 
,,       Scrotal 
Hydatids  (x) 
*Hydrocele 

translucent ;    onset  gradual 
Hydrocele,  Encysted 
(Edema 
Papilloma 

Testicular  Swellings  (926) 
Tumours 
Varicocele 

Sometimes  connected  with  a 
renal  tumour. 


930.  Scrotal  Fistula 

In  advanced  gummatous 
or  tuberculous  cases  there 
may  be  '  f  ungating  hernia 
testis.' 

Abscess 

Extravasation  of  Urine 
Gumma 
Tuberculous  Testis 


931.  Vulva,  Swelling  ol 

*Abscess 
Anasarca  (335) 
Angioma 
Bartholinitis 
Boil 
Cancer 
Caruncle 
Chancre 
Condyloma 
*Cyst,  Dermoid 
„     Sebaceous 
„     Simple 
Diphtheria 
Elephantiasis 
Epithelioma 
Erysipelas 
Fibroma 
Gonorrhoea 
Hematocele 
Hernia 

„       Perinseal 
Hypertrophy 
Hydrocele  of  Canal  of  Nuck 

„  of  the  Sac 

Kraurosis  Vulvae 
Lipoma 
Lupus 
Papilloma 
Sarcoma 
Trauma 
Varix 
Vulvitis 

„         Membranous 
Warts 


932.  Jaequemier's  Sign 

Blueness  of  vaginal  mucosa. 

Pregnancy 
from  12th  week 

929-932 


270 


THE  GENITAL  ORGANS 


933.  Abderhalden's        Dialysis 
Test 

Pregnancy 

Some  doubt  has  ben 
thrown  upon  the  value 
of  this  test.  In  any 
case,  it  is  very  difficult 
to  carry  out. 


934.  Placentin  Test 

Pregnancy 

The  results  are  very 
promising  up  till  now ; 
but  it  is  still  in  the 
experimental  stage. 


935.  Sterility,  Female 

The  proportion  of  infertile 
to  fertile  marriages  within 
the  child-bearing  age  is 
1  to  8 ;  in  75  per  cent, 
the  cause  lies  with  the 
female. 

Absence  of  Vagina  or  Uterus 
Atresia  of  Vagina 
Carcinoma  (x) 
Cervical  Catarrh 


Contracted  Os 
Cystocele 
Elongated  Cervix 
Endometritis 
Fibroids 

Funnel-shaped  Vagina 
Hyperinvolution 
Imperforate  Hymen 
Malnutrition 
Metritis,  Chronic 
Obesity 
Oophoritis 
Ovarian  Atrophy 
,,        Cancer 

Cyst 
„        Fibroid 
Peritonitis,  Old 
Polypus 
Prolapsus  Uteri 
Retroflexion 
Salpingitis 
Sarcoma 
Uterus  Bicornis 

„      ,  Cachleate 

,,      ,  Infantile 
Vaginismus 


933-935 


MICTURITION 


271 


936.  URINATION  OR  MICTURITION 


937.  Frequent 

Ague  (pram.) 

Angina  Pectoris 

Anteflexion 

Ascarides 

Azoturia 

Blood-clots  in  Bladder 

Calculus,  Vesical 
esp.  by  day 

Cancer  of  Bladder 

Cantharides 
*Cirrhosis  of  Kidney 
*Cystitis 

Diabetes  insipidus 
„.       mellitus 

Dysentery 

Dysiuenorrhcea 
*E  motions 

Fistula  in  Ano 

Foreign  Body  in  Bladder 

Gonorrhoea 
posterior 

Gout  (pram.) 

Gravel 

Haemorrhoids 

Hydronephrosis 

Hyperasthesia  of  Bladder 

Hypertrophy  of  Bladder 

Loaded  Rectum. 

Movable  Kidney 
with  torsion 

Nephritis,  Chronic 
Neuralgia  of  Bladder 
Neurasthenia 
Ovarian  Cyst 
while  pelvic 
Over-purgation 
Peritonitis,  I. 


Phimosis 
Proctitis,  Acute 
Prolapse  of  Bladder 
Prolapsus  Uteri 
Prostate,  Enlarged 
esp.  at  night 

Pyelitis,  Chronic 

Pyosalpinx 

Renal  Colic 
♦Retention  with  Incontinence 

Salpingitis 

Stricture  of  Urethra 

Sunstroke 
praemon. 
♦Tuberculous  Bladder 
esp.  by  night 

Tuberculous      Kidney      or 

Urethra 
Tumour  of  Bladder 
Ulcer  of  Bladder 
Urethral  Caruncle 
Urethritis,  Posterior 
Uterine  Congestion 

„        Fibroid 
Villous  Growth 

Also  excessive  acidity  of  the 
urine,  exposure  to  cold, 
and  nervousness. 


938.  Incontinence  of  Urine 

The  best  test  for  incon- 
tinence is  the  inability  to 
interrupt  the  stream 
half-way.  It  is  normal  in 
infants  up  to  the  age  of 
12  to  15  months.  Incon- 
tinence is  not  inconsistent 
with  a  full  bladder. 

936-938 


272 


MICTURITION 


Incontinence    of     Urine — 
continued 
Anaesthesia  of  Bladder 
nocturnal 

Apoplexy 
Ascarides 
Ataxic  Paraplegia 
Atony  of  Bladder 
Atrophy,  Senile 
Cerebral  Tumour 
Coma 

Compression  of  Cord 
Cystitis  (x) 
Cystocele 
women 

Disseminated  Sclerosis 
esp.  sacral  form 

Enuresis  Ureterica 

ureter  opening  into  urethra 
Epilepsy 

nocturnal 

Erb's  Spinal  Paralysis 
Fright 

General  Paralysis,  m. 
Infantile  Paralysis  (x) 
Locomotor  Ataxy 
Meningitis,  Cerebro-spinal 
„  Chronic  Spinal 

Myelitis,  Chronic 
Neurasthenia 
esp.  traumatic  form 
*Over-distension  of  Bladder 

'  retention    with     incontin- 
ence ' 

Oxaluria 
tj  nocturnal 

Paralysis  of  Neck  of  Bladder 

Paraplegia 

Phimosis 

Phosphaturia 


Prostatitis 

Purulent  Spinal  Pachymen- 
ingitis 

Pyuria 

u  nocturnal^ 

Shock 

Softening   of    Cord,    Trans- 
verse 
Spastic  Paraplegia 
Spina  bifida  (x) 
Spinal  Apoplexy 
,,       Concussion 
,,      Meningeal      Haemor- 
rhage 
Super-acid  Urine 
Syph.  Spinal  Paralysis 
Typhic  State  (62) 
Uric  Acid  Excess 
Venereal  Excess 

This  symptom  is  absent  in 
multiple  neuritis,  lateral 
sclerosis,  poliomyelitis, 
and,  practically,  in 
hysteria.  In  spastic 
paraplegia,  it  is  generally 
replaced  by  '  precipitate 
micturition.' 

939.  Enuresis 

Involuntary  micturition  due 
to  spasm  of  the  detrusor 
muscle.  It  is  chiefly 
nocturnal. 

Adenoids 

Balanitis 

Epilepsy 

Fissure  of  Anus 

Faecal  Accumulation 

Hypothyroidism 

Oxaluria 

Phimosis 

Rheumatism 

Vulvitis 

Worms 

938-939 


MICTURITION 


273 


940.  Retention  of  Urine 
Atony  of  Bladder 
Caisson  Disease 
Catarrh  of  Bladder 
Coma 

Diphtheritic  Paralysis 
Dysentery 
Gonorrhoea,  Acute 
Hysteria 

*Impacted  Calculus,  Clot,  or 
Foreign  Body 
Locomotor  Ataxy 
Meningitis,  Cerebro-spinal 
,,  Internal  Spinal 

Myelitis,  Chronic 
Obstruction  of  Ureters 
Paralysis  of  Bladder 
*Pericystitis 
Peritonitis,  n. 
Prostate,  Enlarged 
Rectum,  Impaction  in 
Softening    of    Cord,    Trans- 
verse 
*Spasm  of  Urethra 
Spastic  Paraplegia 
Spina  bifida  (x) 
Spinal    Meningeal    Haemor- 
rhage, I. 
*Stricture  of  Urethra 
Syph.  Spinal  Paralysis 
Tumour  of  Bladder 
Urethritis 

941.  Painful  Micturition 

Concentrated  or  very  acid 
urine  produces  a  burning 
sensation. 

Balanitis 

Calculus,  Ureteral 

impacted  in  orifice 
Calculus,  Vesical 

esp.  in  children 


*Cystitis 

Enlarged  Prostate 

Foreign  Body  in  Urethra 
*Gonorrhcea 

Neuralgia  of  Bladder 

Pelvic  Peritonitis 

Pyelitis 

Sacro-iliac  Disease 
*Stricture 

Tuberculous  Bladder 
cramp  like 

Urethra,  Tuberculous 

Urethral  Caruncle 

„        Chancre 

Urethritis 

When  micturition  is  fol- 
lowed by  a  pricking  sen- 
sation in  the  glans,  there 
is  some  irritation  of  the 
trigone. 

942.  Difficult  Micturition 
(Dysuria,  Tenesmus,  or 
Strangury) 

Acrid  Urine 

Appendicitis  (x) 

*  Calculus,  Vesical 

Cancer  of  Bladder,   Cervix, 

or  Prostate 
Compression  of  Cord 
Concussion,  Spinal 

*  Congestion  of  Kidney 

cantharides,  turpentine,  etc. 

*  Cystitis 
Dysentery 
Dysmenorrhcea 
Fungoid  Bladder 

*Gonorrhcea 
Gravel 

Haemorrhoids,  Inflamed 
Lithaemia 
Locomotor  Ataxy 

940-942 


274 


MICTURITION 


Difficult  Micturition  (Dy- 
suria,  Tenesmus,  or 
Strang  u  r  y  ) — continu  ed 

Metritis,  Acute 

Myelitis 

Neuralgia  of  Bladder 

Ovarian  Cyst 

Paralysis  of  Diaphragm 

Pelvic  Cellulitis 
„       Peritonitis 
„       Tumour 
♦Perineal  Abscess 
♦Phimosis 

Phosphaturia 

Polypus  of  Bladder 

Prolapsus  Uteri 

Proctitis 
♦Prostate,  Enlarged 

Prostatitis 

Pyelitis 

Spasm  of  Urethra 
*Stricture,  Advanced 

Tumour  of  Bladder 

Ulcer  of  Bladder 

Urethral  Chancre 

Urethritis 

Variola  or  Varicella 
vesicles  in  urethra 

Vulvitis 

943.  Diminished  Stream 

Atony  of  Bladder 
small  and  slow 
♦Impacted  Calculus  or  Clot 
Meatus,  Contracted 
*Phimosis 
*Prostate,  Enlarged 
slow  and  feeble 
Prostatitis 
♦Urethral  Stricture 


944.  Interrupted  Stream 

*Calculus 
Clot 
Cystitis 

Foreign  Body  or  Mucus 
Pendulous     Tumour     of 

Bladder 
Spasm  of  Sphincter 
Villous  Tumour 

945.  Suppression   of   Urine   or 
Anuria 

Abdominal  Aneurysm 

„         ^Tumour 
Abscess,  Renal 
Calculus,  Urethral  or  Renal 
Cancer  of  Bladder  or  Uterus 
Cholera 

Enteric  Fever,  in. 
Ether  Inhalation  (x) 
Fevers,  Severe 
♦Hydronephrosis 
Hysteria 
no  uraemic  symptoms 

Kidney,  Cystic 

„        Tuberculous 
Kidneys,  Acute  Congestion 

of 
Nephritis,  Acute 

„  Chronic,  ni. 

Peritonitis  (x) 
♦Pernicious  Anaemia 
Poisoning  by  Lead,  Turpen- 
tine, Chlorate  of  Potash, 
Chloroform,     Cantharides, 
Carbolic    Acid,   Corrosive 
Sublimate,     Mercury     or 
Phosphorus 
Pyelonephritis 
i   Pyonephrosis 
"  Shock 

942-945 


MICTURITION 


275 


Suppression    of    Urine    or 
Anuria — conlimied 
Sunstroke 
Thrombosis,   Renal 

„  of  Inferior  Vena 

Cava 
Tumour,  Large  Pelvic 
„       of  both  Kidneys 
*Typhic  State  (62) 
Uraemia 

Yellow  Atrophy,  Acute 
„       Fever 

Obstruction  of  one  ureter 
may  be  followed  by  arrest 
of  secretion  by  the  other 
kidney. 

Anuria  sometimes  ensues 
upon  an  operation — even 
the  passing  of  a  catheter. 


946.  The  Cystoscope 

Warm  boric  acid  solution 
should  be  injected  into 
the  bladder  until  it  comes 
away  quite  clear.  The 
organ  should  then  be 
distended  with  ten  ounces 
of  the  solution  and  the 
instrument  introduced. 
The  following  conditions 
may  be  detected  : — 

Bladder,  Calculus  of 
„  Polypus  of 

„  Rupture  of 

Tubercle  of 


Bladder,  Ulcer  of 

„         Villous  Growth  of 

Kidney,  Haemorrhage  from 
— renal  rupture,  growth, 
infarct,  or  calculus 

Pyonephrosis,  Discharging 

Ureter  blocked  by  impacted 
Calculus  or  Clot 

947.  Ureteral  Jets 

In  health,  a  jet  of  urine 
lasting  about  two,  and 
recurring  every  thirty, 
seconds  takes  place 
rhythmically  from  each 
ureteral  orifice.  Recur- 
rence is  quicker  when 
there  is  irritation  of  the 
renal  pelvis  {e.g.  pyelitis 
or  calculus)  or  increased 
functional  activity  (e.g. 
from  a  diuretic).  In  the 
latter  case,  the  volume 
may  be  greater. 

A  jet  may  be  purulent, 
sanguineous,  or  absent. 
(See  946.) 

948.  Chromoeystoseopy 

An  intramuscular  injection 
of  4  c.c.  of  4  per  cent, 
solution  of  indigo-car- 
mine is  administered. 

Within  twenty  minutes  a 
very  evident  blue  stream 
will  appear  from  both 
orifices ;  if  from  only  one, 
the  other  kidney  may  be 
absent  or  functionless  or 
there  may  be  obstruction 
to  the  flow. 


T    2 


945-948 


276  URINE  TESTS 


URINE  TESTS 

949.  Sugar. — In  all  chemical  cests  for  glucose,  albumen,  if 
present,  must  be  first  separated  by  boiling  and  filtration.  The 
great  source  of  error,  whether  by  Fehling,  Pavy,  or  Nylander's 
test,  is  the  presence  of  glycuronic  acid  in  the  urine  beyond 
the  very  small  quantity  normally  there.  The  precipitate  with 
Fehling's  solution  is  rather  less  golden  ;  but  otherwise  it  is  only 
distinguishable  from  glucose  by  Bial's  Reagent  (950)  or  phloro- 
glucin.  It  is  found  in  excess  in  persons  taking  morphia,  chloral, 
camphor,  chloroform,  naphthol,  salol,  turpentine,  antipyrin, 
and  carbolic  and  benzoic  acids. 

Fehling' s  Test. — Equal  quantities  of  fresh  Fehling's  solution 
and  urine  should  be  boiled  in  separate  tubes  and  mixed,  and  then 
heated  again.  When  sugar  or  other  reducing  substance  is 
present,  an  orange-red  precipitate  forms  within  two  minutes. 
It  is  well  to  dilute  the  urine  first  so  as  to  bring  the  sp.  gr.  down 
to  1015.  Kreatinin  if  excessive  inhibits  Fehling's  Test  even 
when  sugar  is  really  present.  Uric  acid  in  excess  will  also  give 
the  reaction. 

Phenyl-Hydrazine  Test. — This  is  so  delicate  that  you  per 
cent,  of  sugar  can  be  detected.  As  normal  urine  often  contains 
more  than  this,  the  clinical  value  of  the  test  is  not  great.  It 
has  the  advantage,  however,  of  giving  no  result  with  glycuronic 
acid. 

Nylander's  Test  (modified).  — The  original  reagent  was  not 
only  difficult  to  make,  but  it  had  the  disadvantage  of  keeping 
very  badly  ;  otherwise,  it  was  most  satisfactory  and,  unlike 
Fehling,  gave  no  reaction  with  constituents  of  normal  urine. 
En  revanche,  it  was  not  available  when  the  patient  was  taking 
salol,  antipyrin,  rhubarb  or  senna,  and  it  gave  a  precipitate  with 
lactose.  It  occurred  to  the  writer  that  the  soluble  tartrate 
of  bismuth  introduced  by  Messrs.  Burroughs  Wellcome  &  Co. 
ought  to  answer  equally  well,  and  this  proves  to  be  the  case. 
The  reagent  consists  of  a  solution  containing  1  per  cent,  of 
bismuth  tartrate  and  8  per  cent,  of  sodium  hydrate.  On  boiling 
this  with  an  equal  quantity  of  urine  for  a  minute  a  deep  black 
precipitate  forms  on  standing.  The  solution  keeps  well,  and 
will  detect  the  presence  of  0"1  per  cent,  of  glucose. 

949 


URINE  TESTS  277 

Fermentation  Test. — This,  though  tedious,  does  at  least 
give  an  indisputable  verdict.  A  piece  of  compressed  yeast 
the  size  of  a  hazel-nut  is  put  in  100  c.c.  (3-|  oz.)  of  urine,  covered 
over,  and  kept  from  twenty-four  to  thirty-six  hours  at  room 
temperature.  When  fermentation  is  finished,  foam  will  cease 
to  form  and  the  yeast  will  sink  to  the  bottom.  The  difference  be- 
tween the  sp.  gr.  before  and  after  fermentation,  multiplied  by  0*23, 
will  give  the  percentage  of  sugar  contained  in  the  specimen. 
The  temperature  should  be  much  the  same  at  each  testing. 

The  Polariscope. — It  must  be  remembered  that  if  both 
dextrose  and  lrevulose  are  present  the  result  may  be  negative. 
/3-oxybutyric  acid  is  lsevorotary  (see  Acetone,  966). 

The  Glucose  Test  is  employed  when  sugar  is  strongly  sus- 
pected and  cannot  be  detected  by  ordinary  means.  The  patient 
is  given  3J  oz.  of  glucose,  fasting,  and  the  urine  is  examined 
four  hours  afterwards  ;  in  health  none  will  be  found. 

Quantitative  Test. — This,  when  once  sugar  ha3  been  proved  to 
be  present,  may  be  estimated  approximately  by  Gowers'  Test. 
Equal  parts  of  urine  and  liquor  potassse  are  boiled  together  and 
the  colour  noted.  Lemon  yellow  indicates  5  per  cent,  of  sugar  ; 
pale  sherry,  10  per  cent.  ;  dark  sherry,  15  per  cent.  ;  and  port- 
wine  colour,  20  per  cent,  or  more. 

Gerrard's  Test. — To  make  this  reagent,  dilute  100  c.c.  of 
Fehling  with  300  c.c.  water  and  boil  in  a  porcelain  basin  ;  then 
run  in  gradually  a  5  per  cent,  solution  of  cyanide  of  potash. 
When  the  colour  has  gone,  dilute  to  500  c.c,  and  keep  in  a 
well-stoppered  bottle.  When  testing  for  sugar,  add  10  c.c.  of 
Fehling  to  50  c.c.  of  Gerrard's  reagent  and  boil  in  a  porcelain 
basin.  Run  in  the  urine  slowly  and  watchfully  till  the  colour 
has  gone.  If  1  c.c.  suffices  for  discoloration  there  is  0*5  part 
of  sugar  per  cent,  present  ;  if  2  c.c,  0.25  part  per  cent.  ;  if 
5  c.c.  are  necessary,  0*1  per  cent,  sugar,  and  so  on. 

950.  Pentose. — This  also  gives  Eehling's  reaction  ;  but, 
since  its  presence  has  no  importance,  it  must  be  differentiated 
from  glucose.  This  can  be  done  with  Bial's  Reagent,  4  c.c.  of 
which  are  heated  to  boiling-point  and  10  drops  of  urine  added. 
A  beautiful  green  colour  will  develop  within  a  few  seconds. 
Pentose  does  not  ferment  yeast. 

951.  Albumen. — The  urine  must  be  clear  to  start  with, 
or  made  so  by  nitration,  or,  in  the  case  of  urates   by  gentle 

949-951 


278  URINE  TESTS 

heat.  The  conventional  test,  by  adding  nitric  acid  after  boiling, 
may  mislead  if  either  too  much  or  too  little  acid  is  used.  The 
proper  proportion  is  10  drops  to  10  c.c.  Acetic  acid  is  pre- 
ferable therefore  ;  acidulate  with  a  little  of  this  and  then  boil 
the  upper  half  ;  should  albumen  be  present,  a  flocculent  pre- 
cipitate will  form  which  is  not  dissolved  when  nitric  acid  is 
added.  Or  a  saturated  solution  of  picric  acid  may  be  used  ; 
when  drops  of  urine  are  allowed  to  fall  into  this,  they  leave  a 
cloudy  track  if  albumen  or  albumose  be  present ;  but  the  latter 
redissolves  on  heating,  while  the  albumen  is  unaffected  ;  the 
test  is  only  of  negative  value.  In  MacWilliam's  test  half  a 
drachm  of  urine  is  placed  in  a  very  small  test-tube,  with  a  few 
crystals  of  salicyl-sulphonic  acid  added  cold.  If  there  is  no 
precipitate,  there  is  no  albumen  ;  if  there  is,  it  will  clear  up  on 
boiling  if  due  to  albumose,  but  not  if  due  to  albumen.  This 
test  is  likely  to  supersede  all  others. 

952.  Esbaeh's  Albuminometer. — This  is  used  for  the  quan- 
titative analysis.  The  reagent  consists  of  picric  acid  10  grammes, 
citric  acid  20  grammes,  boiling  water  1  litre.  The  tube  is  filled 
up  to  U  with  urine,  and  the  reagent  (cold)  is  added  till  R  is 
reached.  The  precipitated  albumen  is  examined  twenty-four 
hours  later,  when  the  graduation  reached  will  give  the  number  of 
grammes  per  litre,  or,  divided  by  ten,  the  percentage  of  albumen. 
To  get  the  number  of  grains  per  ounce,  multiply  the  percentage 
by  4*375.  An  ordinary  case  of  albuminuria  shows  about  |  per 
cent.     The  test  is  not  reliable  for  very  small  quantities. 

953.  Nucleo-Proteid. — It  is  derived  from  the  epithelium  of 
the  ureter,  bladder,  and  urethra,  and  is  often  due  to  the  irritation 
of  crystals.  When  urine  yields  a  cloud  on  boiling,  it  may  be  due  to 
a  mixture  of  phosphates  and  nucleo-protein.  Acetic  acid  will 
dissolve  the  phosphates,  but  not  the  nucleo-protein.  Nitric 
acid  dissolves  both. 

954.  Albumose. — Filter  off  the  precipitate  of  albumen. 
On  the  addition  of  liquor  potassse  and  a  few  drops  of  a  1  per 
cent,  solution  of  sulphate  of  copper  to  the  filtrate,  a  violet  colour 
will  develop. 

955.  Bence-Jones'  Albumen. — This  coagulates  at  the  low 
temperature  of  50°  C,  the  precipitate  re-dissolving  on  being 
boiled. 

951-955 


URINE  TESTS  279 

956.  Urea. — A  sp.  gr.  of  1014  corresponds  to  about  1  per 
cent,  of  urea  ;  of  1018,  to  1*5  per  cent.  ;  of  1022,  to  2  per  cent.  ; 
and  of  1028,  to  about  3  per  cent.  That  is,  provided  no  sugar 
or  albumen  is  present. 

957.  Uric  Acid. — The  laboratory  quantitative  test  for  this 
is  rather  complicated,  and  the  clinical  application  of  the  results 
is  by  no  means  universally  admitted.  The  last  two  figures  of  the 
sp.  gr.  multiplied  by  2  give  approximately  the  number  of 
centigrams  of  uric  acid  per  litre.  The  presence  of  uric  acid  can 
be  determined  by  the  murexide  test  (1046). 

958.  Bile. — Bile-pigment  is  detected  by  putting  a  little  of 
the  urine  on  a  porcelain  plate  in  lateral  contact  with  a  few  drops 
of  strong  nitric  acid,  when  lines  of  green  and  other  colours  will 
be  observed  between  them  (Gmelin's  Test). 

959.  Lead. — A  drop  of  urine,  greatly  concentrated  by  evapora- 
tion, is  allowed  to  fall  into  a  tall  glass  containing  ammonium 
sulphide.  The  descending  drop  will  leave  a  white  trail  if  lead 
is  present. 

960.  Total  Solids. — If  these  are  determined  by  evaporation, 
some  acetic  acid  must  be  added  to  prevent  decomposition,  and 
the  temperature  must  not  exceed  60°  C.  Trapp's  Formula  consists 
in  multiplying  the  last  two  figures  of  the  sp.  gr.  by  2*2337.  The 
results  will  give  the  number  of  grammes  per  litre. 

961.  Casts,  Crystals,  etc. — The  urine  must  be  left  to  stand 
in  a  conical  glass  for  a  couple  of  hours  or  more.  A  little  of  the 
sediment  taken  up  with  a  pipette  is  dropped  upon  a  glass  side, 
covered,  and  examined  with  a  quarter-inch  objective.  Only 
moderate  illumination  should  be  employed  for  casts.  The  use 
of  a  centrifuge  greatly  hastens  matters. 

962.  Blood. — This  may  be  fairly  abundant  even  in  pale  urine. 
On  boiling  with  one-third  its  volume  of  liquor  potassae  a  well- 
marked,  red,  flocculent  precipitate  will  gradually  form  if  blood 
be  present  (Heller's  Test) — though  the  test  is  vitiated  if  the 
patient  has  been  taking  santonin,  rhubarb,  ;  or  senna.  The 
guaiacum  test  is  more  accurate,  but  it  must  be  remembered 
that  iodides  in  the  urine  give  the  blue  coloration,  though  more 
slowly  and  only  in  the  upper  stratum.  A  mixture  of  equal 
parts  of  tincture  of jguaiacum  and  ozonic  ether  is  allowed  to  run 

956-962 


280  URINE  TESTS 

upon  the  surface  of  some  acid  urine  in  a  test-tube.  A  blue  ring 
is  gradually  formed  at  the  junction  of  the  two  fluids  if  blood 
be  present.  Urine  containing  much  saliva  also  gives  the  blue 
reaction.     (See  Pus,  964.) 

The  coagulate  produced  by  boiling  urine  containing  blood  is 
usually  of  a  dirty  brown  colour.  A  little  blood  goes  a  long  way, 
and  it  is  useful  to  know  how  much  blood  a  given  precipitate 
represents.  I  have  found  by  experiment  that  the  addition 
of  2  per  cent,  of  blood  yields,  after  standing  twelve  hours,  a 
deposit  amounting  to  £  of  the  height  of  the  fluid  in  the  tube. 

963.  Uryhsematin. — The  hsematin  is  sometimes  converted 
into  uryhsematin  ;  the  urine  is  then  pale.  To  restore  the  red 
colour  add  hydrochloric  acid. 

964.  Pus. — Agitation  with  ether  shows  fat  on  evaporation. 
The  addition  of  liquid  potash  converts  pus  into  a  ropy  gelatinous 
mass.  Tincture  of  guaiacum  gives  a  greenish  colour,  which 
disappears  on  boiling. 

965.  Diazo-Reaction  (Ehrlich). — A  mixture  of  50  c.c.  of  half 
per  cent,  solution  of  sulphanilic  acid,  with  1  c.c.  of  half  per  cent, 
solution  of  nitrite  of  soda,  is  added  to  an  equal  quantity  of  urine, 
and  then  well  shaken  with  one-eighth  the  volume  of  ammonia. 
A  bright  red  foam  will  result  in  certain  cases.  The  examination 
should  be  made  by  daylight  and  the  reagents  must  be  fresh. 

966.  Acetone. — A  few  drops  of  sodium  nitro-prusside  are 
shaken  up  with  some  of  the  urine,  and  a  dram  or  two  of  strong 
solution  of  ammonia  is  gently  poured  upon  it.  A  magenta  (not 
violet)  ring  forms  at  the  junction  (Legal's  Test).  In  doubtful 
cases  a  distillate  of  the  urine  should  be  employed.  A  rough 
clinical  test  consists  in  giving  a  large  dose  of  carbonate  of  soda. 
The  urine  a  few  hours  after  will  be  alkaline  in  health,  but  acid 
in  acetonuria. 

967.  Diaeetic  Acid. — Dilute  perchloride  of  iron,  let  fall  drop 
by  drop,  gives  a  red  tint  which,  unlike  that  due  to  salicylates, 
is  discharged  by  warming. 

968.  Methylene  Blue  Test. — One  c.c.  of  5  per  cent,  solution 
of  pure  methylene  blue  is  injected  into  the  gluteus  maximus. 
The  urine,  if  normal,  shows  within  half  an  hour* a  green  tint, 
which  goes  on  deepening  in  colour  for  the  next  three  hours.     The 

962-968 


URINE  281 

colour  is  diminished  in  interstitial  nephritis.  In  rare  cases  the 
methylene  blue  is  excreted  as  colourless  '  chromogen,'  but  on 
boiling  it  with  a  little  acetic  acid  the  colour  will  be  restored. 
The  test  is  specially  valuable  when  used  with  urine  separated  by 
Luys'  instrument.     (See  also  Cystoscope,  946.) 

969.  Sahli's  Desmoid  Reaction. — Iodoform,  enclosed  in  a 
rubber  bag  tied  round  with  catgut,  is  given  by  the  mouth. 
Normally,  iodine  should  be  detected  in  the  urine  in  from  four 
to  eight  hours.  If  it  is  much  later  than  this,  or  absent,  there  may 
be  pancreatic  disease  or  exaggerated  motility  of  stomach.  The 
test  is  based  upon  the  belief  that  non-sterilised  catgut  can  only 
be  digested  by  the  gastric  juice.  Schlesinger,  however,  affirms 
that  the  intestinal  juices  can  digest  it. 

970.  Freezing  Point. — In  the  absence  of  sugar  or  proteid, 
the  last  two  figures  of  the  sp.  gr.  multiplied  by  0'075  will  give 
the  freezing  point  Centigrade. 

971.  Cathelin  or  Luys'  Urine  Separator. — The  instrument 
consists  roughly  of  a  double  catheter  with  a  segmental  mem- 
brane filling  up  the  curve,  so  that  the  secretion  of  each  kidney 
can  be  examined  separately. 

Calculi,  Tests  for,  see  1046. 

972.  QUANTITY 

'  For  quantitative  analysis  of  any  given  constituent,  a  specimen 
must  be  taken  from  the  urine  collected  during  24  hours.  This  in 
an  adult  should  be  about  50  ounces.  More  is  passed  by  day  than 
by  night. 

973.  Quantity  Increased  (Poly-        ^Cirrhosis  of  Kidney,  in. 

uria)  sometimes  enormous  quan- 


tities 
Cystic  Kidney 


Acromegaly 
Acute  Diseases 

convalescent  stage  *Diabetes  insipidus 

Amyloid  Kidney  *Diabetes  mellitus 

Ansemia 
Angina  Pectoris 

following  the  attack 
Asthma,  Spasmodic 

following  the  attack 
Chorea 


Enteric  Fever,  m. 

a  favourable  sign 
Epilepsy 

following  attack 


Floating  Kidney 
Chlorosis  following  Dietl's  Crisis 

968-973 


282 


URINE 


Quantity     Increased 

(  Polyuria) — continued 

Hydronephrosis 

coincidently  with  the  dis- 
appearance of  the  lumbar 
swelling 

*Hysteria 

following  attack 
Locomotor  Ataxy 
Malaria 

cold  stage 
Migraine 
Myxcedema 
Neurasthenia 
Paralysis  Agitans 
Phosphatic  '  Diabetes ' 
Resorption  of  Effusions 
Tuberculous  Kidney 
Tumour,   Cerebellar,  Bulbar 

or  Spinal 

Also  after  copious  drinking  ; 
after  foods  containing 
citrates  or  tartrates,  and 
after  diuretics,  including 
tea,  coffee,  whisky,  gin, 
beer,  hock, and  phloridzin. 

974.  Quantity  Greater  at  Night 
Arterio-  sclerosis 
Cachexia 

♦Diabetes 
Heart  Disease 
Kidney  Disease 

975.  Quantity      Diminished 
(Oliguria) 

Abdominal     Aneurysm    or 
Tumour 
by  pressure 

Ascites  (late) 

Atrophy  of  Kidney,   Acute 


Cholera 

Collapse  of  Lung 

Congestion  of  Kidney 
♦Diarrhoea 

Dilatation  of  Stomach 

Embolism  of  Kidney 

Fatty  Kidney 

Gastritis,  Chronic 

Gout 

Heart  Failure 

Influenza 

Intestinal  Obstruction 
*Lead  Colic 

Mechanical  Obstruction 

Melancholia 
♦Nephritis,  Acute 

„  Chronic  Tubal 

Peritonitis 

Pleurisy  with  Effusion 

Pneumonia 

Pneumothorax 

Pyrexia  (295) 

Relapsing  Fever 

Thrombosis  of  Inferior  Vena 

Cava  or  Renal  Vein 

♦Vomiting,  Prolonged 

Also  abstention  from  fluids, 
excessive  perspiration,  etc. 

(See  Retention,  940,  and 
Suppression,  945.) 

976.  Opsiuria 

The  excretion  of  urine 
during  fasting  is  greater 
than  it  is  a  few  hours 
after  a  full  meal  (Gilbert's 
Sign). 

Cirrhosis  of  Liver 


973-976 


URINE 


283 


977.  REACTION 

The  reaction  is  ascertained  by  dipping  in  the  urine  the  end  of 
a  strip  of  litmus  paper.  If  acid,  blue  litmus  is  turned  red  ;  if 
alkaline,  red  litmus  is  turned  blue.  On  heating,  this  blue  colour 
remains  if  the  change  is  due  to  a  fixed  alkali  such  as  soda  or  potash  ; 
but  disappears  if  due  to  the  volatile  alkali,  ammonia.  An  amphoteric 
reaction  means  that  blue  litmus  is  turned  red,  and  red  blue. 

The  normal  acidity  of  the  urine  is  due  to  the  presence  of  acid 
sodium  phosphates.  It  is  neutral  or  faintly  alkaline  during  digestion 
and  acid  when  fasting.  All  urine  becomes  alkaline  after  long 
exposure  to  the  air,  owing  to  the  growth  of  micrococcus  ureae,  which 
forms  ammonium  carbonate  from  urea. 


978.  Super-acid 

Ague    Paroxysm 
Dilatation  of  Stomach 
Fevers 
Gout 

Leuksemia 
Lithsemia 

Paroxysmal      Hemoglobin- 
uria 
Pyelitis 
*Rheumatism,  Acute 
Uric  Acid  Calculus 

Also  after  eating  cheese, 
meat,  and  cereals. 

979.  Sub-acid 

(of  little  significance) 

Chlorosis 

Ingestion  of  Fruit  or  Pota- 
toes 

980.  Amphoteric 

Due  to  the  presence  in  de- 
finite proportions  of  acid 
di-hydrogen  phosphate 
and  alkaline  di-sodium 
phosphate.  Significance 
unimportant. 


981.  Alkaline 

(a)   Volatile  Alkali 

Acute  Yellow  Atrophy 
Ague  (intervals) 
Anasarca 
Ascites 

Calculus,  Vesical 
Cystitis 

Gastric  Irritation 
Hyperchlorhydria 
*Retention 
Spinal  Injury 
Tuberculosis    of    Urinary 

Tract 
Vegetable  Diet 

(&)  Fixed  Alkali 

Anaemia 

Atony  of  Stomach 

Chlorosis 

Ingestion  of  Alkalies 

Neurasthenia 

'  Phosphaturia ' 

Prostration 

Rheumatism 


977-981 


284 


URINE 


982.  THE  SPECIFIC  GRAVITY 

This  is  taken  with  a  urinometer.  If  the  quantity  of  urine  is 
insufficient,  multiples  of  water  should  be  added  and  a  calculation 
made  accordingly.  Thus  with  an  equal  quantity,  multiply  the  last 
two  figures  by  two  ;  with  twice  as  much  water  by  three,  and  so  on. 
Or  sp.  gr.  beads  may  be  used.  The  sp.  gr.  is  increased  by  cooling, 
but  is  very  little  affected  by  matters  in  suspension.  The  normal 
sp.  gr.  is  1015-1025. 


983.  High  Specific  Gravity 
From  1025  to  1045 

Anasarca 

Congestion  of  Kidney 
*Diabetes  Mellitus 

rarely,  normal 
*Gout,  Acute 

Haematuria 

Heart  Failure 

Leukaemia 

Lithaemia 

Nephritis,  Acute 

Oxaluria 

Pneumonia,  Acute 
*Pyrexia  (295) 

Rheumatism,  Acute 

Also  after  repletion,  long 
retention,  vomiting,  diar- 
rhoea, profuse  perspira- 
tion, and  ingestion  of 
phloridzin. 


984.  Low  Specific  Gravity 
Under  1010 

Ague  (cold  stage) 
Amyloid  Kidney 

*  Anaemia 

Atony  of  Stomach 
Chyluria 

*  Cirrhosis  of  Kidney 

markedly  lowered 

Cystic  Disease  of  Kidney 
*Diabetes   Insipidus 

,,  '  Phosphatic  ' 

Epilepsy 
after  fit 

Gout,  Chronic 
*Hysterical  Seizure 
'  Urina   spastica  ' 
Hydronephrosis 

intermittent 

Myxcedema 

Nephritis,  Chronic  Tubular 
slightly  lowered 

Polycythaemia,      Splenome- 

galic 

Polyuria,  Nervous 

Also  after  fasting,  copious 
drinking,  and  diuretics, 
and  in  convalescence  from 
acute  disease. 


982-984 


URINE 


285 


985.  COLOUR 

The  normal  colour  is  that  of  pale  sherry.     It  is  due  to  urochrome. 
A  high  colour  is  due  to  urobilin  and  a  pinkish  tint  to  uroerythrin. 


986.  Pale  Urine 
Ague  (prsem.) 
Amyloid  Kidney 

♦Anaemia  (385) 

Asthma,  Spasmodic 

Chlorosis 
♦Cirrhosis  of  Kidney 

Convalescence 

Copious  Drinking 

Cystic  Kidney 

Diabetes 

„       Insipidus 

Diuretics 

including  alchohol 

Epilepsy 

Gout,  Chronic 
*Hysteria 

Stomach,  Atony  of 

Tannin  internally 

Uryhsematuria 

it    turns    red    with    hydro- 
chloric acid 

987.  High  Colour 

Cancer  of  Liver 

Cirrhosis  of  Liver 

Congestion  of  Kidney 

Cyanotic  Liver 

Duodenal  Catarrh 

Dysentery 

Dyspepsia 

Gastritis 
*Gout 

Hepatitis,  Acute 

Influenza 
*Lith8emia 


Nephritis,  Chr.  Tubular 
Oxaluria 
Peritonitis 
Pernicious  Ana?mia 
Pyrexia  (295) 

Also  from  exercise,  food, 
perspiration,  and  from 
taking  rhubarb,  saffron, 
santonin,  or  turmeric. 

988.  Blue  Urine 
Methylene  Blue,  Ingestion  of 

in  drugs  or  confectionery 

Oxidation  of  Indican  (x) 
(See  Indican,  1022) 

989.  Green  Urine    ' 
Chloroma 
Cystinuria 

after   decomposition 

Fuchsin 

Methylene  Blue 

Pink  musk  lozenges  have 
produced  an  opalescent 
green  urine. 

990.  Opalescent  Urine 
Bacilluria 

Suspended  matters  or  a 
little  blood  will  cause  it. 

991.  Pink  Urine 
Chrysophanic  Acid 

in  alkaline  urine 

Picric  Acid  poisoning 
Rosanilin 

985-991 


286 


URINE 


992.  Reddish  Urine 

Rhubarb,  senna,  purgen, 
antipyrin,  santonin,  and 
cascara  give  a  reddish 
colour  to  alkaline  urine. 

993.  Violet  Urine 

Fuchsin 
Methyl  Violet 
used  in  gonorrhoea 

994.  Brown  to  Black 

Alkaptonuria 

turns  black  on  standing  or 
on  the  addition  of  an 
alkali 

Indicanuria  (x) 
*  Jaundice,  Chronic 
Melanotic  Cancer 
after  standing 

Ochronosis 

turns  black  with  ferric 
perchloride 

*Paroxysmal      Hemoglobin- 
uria 
Pernicious  Anaemia  (x) 

Also  after  ingestion  of 
carbolic  acid,  exalgin, 
creasote,  salol,  naphtha- 
lene, gallic  acid,  uva  ursi, 
tar,  or  resorcin. 

995.  Smoky  Urine 

Usually  due  to  renal 
haemorrhage  (methaemo- 
globin).  See  Hsematuria, 
1000. 

996.  Milky 

Fatty  (Chyluria) 
Filariasis 
Nephritis  (x) 
Thoracic  Duct  Obstructed 

from  tumours  or  injuries 


Non-Fatty 
Bi-Phosphates 
chiefly  after  food 

Urates,  White 

Malingerers  add  milk — 
acetic  acid  will  curdle 
this. 

997.  Frothy  Urine 
On  shaking : — 

Mucus,    Albumen,    Bile,    or 
Sugar  {q.v.) 
On  adding  an  acid  : — 
Calcium  Carbonate 

998.  Urine  Odorous 

Acetonuria 
Like  over -ripe  apples 

Bacilluria 
fishy  (B.  coli) 

Chyluria 

milk-like 
Cystinuria 

sweet  briar-like 
Cystitis 

ammoniacal ' 
Diabetes 

apple-like 
Nephritis,  Acute 

like  beef-tea 
Recto-vesical  Fistula 

faecal 
Turpentine,    Ingestion    of 

like  violets 

Asparagus,  cubebs,  copaiba, 
and  saffron  give  a  peculiar 
odour  to  the  urine. 


992-998 


URINE 


287 


999.  Non-Decomposing    Urine 

Hemoglobinuria 
for  years 

Haematoporphyrin 
Tuberculosis 
for  many  days 


1000.  Hematuria 

Haemoglobin  in  corpuscles. 
The  blood  is  evenly  dif- 
fused and  generally  smoky 
in  renal  haemorrhages, 
precedes  clear  urine  in 
urethral  haemorrhage,  and 
often  follows  the  clear 
urine  in  bladder  cases. 

Abscess,  Pelvic 
rupturing  into  bladder 

Aneurysm,  Renal 
Angioma 

Appendicitis,  Acute  (x) 
Arterio-sclerosis 
Asthma 
Bilharzia 
profuse 

Calculus,  Renal,  Vesical,  or 

Ureteral 

increased  by  movements — 
from  oxalic  acid  (it)  ;  from 
uric  acid  (x) ;  from  phos- 
phatic  calculus,  never. 

Cancer  of  Kidney,  Rectum, 
Uterus,  Bladder,  or  Pros- 
tate 
increased  by  movements 

Catheterism 
Chloroma 
Cholera 

Concretions  in  Tubules 
Congestion  of  Kidney, 
Active 


Cystic  Kidney,  in. 
intermittent 

Cystitis,  Acute  (x) 
Diphtheria 
Embryoma 

Endocarditis,  Malignant 
Epithelioma  of  Bladder 
Filariasis 
Foreign  Body 
in  urinary  tract 

Gonorrhoea 
Haemophilia 
Hydronephrosis  (x) 
Hypernephroma 
intermittent 

Infantile  Scurvy 
Infarct,  Renal 
'  renal  epistaxis  ' 

Injury 
*Irritants 

e.g.  cantharides  or  turpen- 
tine 

Jaundice  (x)  (392) 

Leukaemia 

Malaria  (x) 
*Menstruation 
*Metrorrhagia 

Movable  Kidney 
kinked  renal  vein 

Nephritis,  Acute 
„  Chronic 

large   red   variegated,    and 
small  white  kidney 

Nephritis,  Suppurative 
Neurasthenia  (x) 
Oxaluria 

Papilloma  of  Pelvis 
Pernicious  Intermittent 
Plague 

999-1000 


288 


URINE 


Hematuria — continued 
Poisoning  by  Phosphorus 
Prostate,  Tuberculous 

„  Tumour  of 

Prostatitis 
*Purpura  hemorrhagica 
Pyelitis,  Acute 
Relapsing  Fever 
Remittent  Fever 
Salpingitis,  Acute  (x) 
Sarcoma  of  Kidney 
Scarlatina  Maligna 
Scurvy 

Thrombosis  of  Renal  Vein 
Tubercle  of  Bladder 
„       of  Kidney 
,,       of  Urethra 
Ulcer  of  Bladder 
intermittent 

Ulceration  in  rest  of  Urinary 

Tract 
Urethritis,  Acute 
Variola,  Malignant 
Villous  Growth  of  Bladder 

profuse 

Yellow  Fever 

It  occurs  also  in  persons 
taking  cantharides,  tur- 
pentine, carbolic  acid  or 
urotropin  (x) 

1001.  Hemoglobinuria 

Free  hsemoglobin — haemo- 
lysis. The  colour  of  the 
urine  may  be  pink,  bright 
red,brown,smoky  or  black. 

Angio-neurotic  (Edema 

Anthrax 

Chlorosis 

colourless  =uryhgemoglobin 

Haemorrhages,  Large 


Hemoglobinuria,  Infantile 
Henoch's  Purpura 
Malaria  (x) 
Nephritis  (x) 
^Paroxysmal  ]    Hemoglobin- 
uria 
Rabies 

Raynaud's  Disease 
Septicaemia 
Yellow  Fever 

This  condition  also  occurs 
after  burns  or  transfusion 
of  blood  and  in  cases 
of  poisoning  by  chlorate 
of  potash,  antifebrin, 
arseniuretted  hydrogen, 
naphthol,  urotropin, 

nitro-benzol,  sulphuretted 
hydrogen,  and  carbolic, 
hydrochloric,  pyrogallic, 
and  sulphuric  acids.  Over- 
exertion will  sometimes 
induce  it. 


1002.  Haematoporphyrin 

Dark     red    urine    due    to 
iron-free  hematin — rare. 

Addison's  Disease 
Chorea 

Enteric  Fever 
Exophthalmic  Goitre 
Hydroa  iEstivale 
Measles 
Meningitis 
Pericarditis 
Peritonitis 
*Pernicious  Anemia 
Pneumonia 
Rheumatism,  Acute 

Action  of  sulphonal  (esp.  in 
women),  trional,  tetranol. 

(See  Pink  Urine,  991) 
1000-1002 


URINE 


289 


1003.  Clots 

A  clot  formed  in  the  urethra 
or  ureter  is  cylindrical. 

Bladder,  Ruptured 
Cancer  of  Kidney 
vermicular  or  pyramidal  in 
shape 

Chyluria 
white 

Hypernephroma 
♦Menstruation,  etc. 

Renal  Calculus 

Trauma 

Ulcer  of  Bladder 

Urethra,  Ruptured 
♦Villous  Growth 
(See  1000) 

1004.  Albumen 

For  tests  see  951. 

Albuminuria  has  been 
divided  into  prae-renal  (as 
in  mitral  disease),  renal 
(when  it  comes  from  the 
kidney),  and  post-renal. 

Abdominal  Aneurysm 
Acute  Yellow  Atrophy 
Albuminuria,  Postural 
Alcoholic  Coma 
Alcoholism,  Chronic 
Amyloid  Disease 
Angio -neurotic  (Edema 
Ankylostomiasis 
Arsenic-poisoning,  Chronic 
Ascites,  Extensive 
Atrophy  of  Kidney,  Acute 
Bronchitis,  Chronic 
little 

Burns 

Cerebral  Tumours 

Cerebro  -spinal  Meningitis 

Cholera 


D 


Cirrhosis  of  Kidney 

little  or  none 
Cirrhosis  of  Liver  (x) 
Congestion  of  Kidney 

little 
Cystic  Kidney 

intermittent 
Diabetes 

40  per  cent,  of  cases 
*Diphtheria 

third  or  fourth  day 
Displacement  of  Heart 
Eclampsia  Gravidarum 
Embolism  of  Kidney 
Emphysema 

a  little 

Endocarditis 

Enteric  Fever 

a  little  in   25   per  cent,  of 
cases 

Epilepsy 
for  2  days  after  a  fit 

Erysipelas 

Exophthalmic  Goitre 

Fatty  Kidney 

Fevers,  Most 
a  little 

Gout  (x) 

Hemoglobinuria,     Paroxys- 
mal 

Hepatitis,  Acute 

Hydrophobia 

Hyperpyrexia 

Influenza  (x) 

Lead-poisoning 

Leukaemia,  Spleno-medul- 
lary 

Lordosis 

Lymphadenoma 

Mediastinitis 

Medulla,  Lesion  of 

1003-1004 


290 


URINE 


Albumen — continued 
Mercurialism 
Mitral  Regurgitation 
Morphinism 
Mumps 
""Nephritis,  Acute 

much 
Nephritis,  Chronic  Tubular 

much  at  first,  less  later 
Nervous  Paroxysms 
Neurosis,  Vasomotor 
Obstruction  to  Vena   Cava 

Inferior 
Ovarian  Tumours 
Pancreatitis 
Paratyphoid 
Peliosis  Rheumatica 
Pemphigus 
Pernicious  Anaemia 

„  Intermittent 

Phosphoru  s  -poisoning 
Pneumonia,  Acute 

a  little 
Polycythemia,    Splenome- 

galic 
Pregnancy 
Psittacosis 
Rabies 

Raynaud's  Disease 
Remittent,  Severe 
Rheumatism,  Acute 
Salicism 
Scabies 
Scarlatina 

Suppurative  Nephritis 
Syphilitic  Nephritis 

abundant 
Thrombosis  of  V.  Cava 
Tricuspid  Regurgitation 
Tuberculosis,  Acute 

a  little 


Tuberculous  Kidney,  I. 
Tumours,  Abdominal 

,,  Renal 

Ulcer,  Gastric  (x) 
Urethra,  Obstructed 
Variola 
Weil's  Disease 
Yellow  Fever 

***  Caution  :  albumen  may  also 
be  derived  from  blood, 
pus,  or  semen,  and 
may  appear  temporarily 
in  those  taking  lead, 
mercury,  carbolic  acid, 
balsam  of  Peru,  storax, 
suprarenal  extract,  etc. 
It  is  found  in  healthy 
babies. 

1005.  Postural  Albuminuria 

Albuminuria  is  found  in 
some  apparently  healthy 
individuals,  especiall}' 
after  excitement,  active 
exercise,  or  heavy  nitro- 
genous meals,  but  ceases 
when  the  patient  is  re- 
cumbent, and  is  therefore 
absent  in  the  morning. 
It  is  often  associated  with 
lordosis  and  with  movable 
kidney,  and  is  thought 
by  some  to  be  a  prsetuber- 
culous  symptom,  and  by 
others  to  indicate  a  vul- 
nerability to  Bright's  Dis- 
ease in  the  distant  future. 

Conversely,  there  is  a  form 
of  intermittent  albumin- 
uria associated  with  en- 
larged spleen  and  due  to 
pressure  upon  the  renal 
vein.  This  ceases  when 
the  patient  is  erect 
(Rolleston). 

Another  intermittent  form 
follows  upon  fatigue,  such 
as  that  of  marching 
(Ratherg). 

1004-1005 


URINE 


291 


1006.  Bence-Jones'  Albumen 

This  has  now  been  shown 
to  be  a  true  protein. 

Bone,  Malignant  Disease  of 
Chloroma  (x) 
Leukaemia  (x) 
Lymphosarcoma  (x) 
Mollities  Ossium 
*Multiple  Myelomata 
in  50  per  cent,  of  cases 

Myxo3dema  (x) 

1007.  Albumose 

Albumose  coagulates  at 
140°,  the  precipitate  re- 
dissolving  on  boiling. 
For  other  tests  see  954. 

Abscess,  Appendicular 

„  Hepatic 

Acute  Yellow  Atrophy 
Bronchiectasis 
Cancer  of  Digestive  Tract 
Cirrhosis  of  Liver 
Diphtheria 
Empyema 
Enteric  Fever 
Infarcts 
Influenza 
Gangrene 
Leukaemia 
lymphatic  form 

Liver  Diseases 

Measles 

Meningitis,  Purulent 

Mollities  Ossium 

Mumps 

Myelosarcoma 

Myx  oedema 

Pernicious  Anaemia 

Phthisis,  m. 

Pneumonia,  Acute,  m. 


Pregnancy 

esp.  on  death  of  foetus 
Puerperal  state 
Rheumatic  Fever 
Scarlatina 
Septicaemia 
*Suppurative     Processes     in 

general 
Syphilis 
Ulcer  of  Intestine 

**  Albumosuria  has  no  rela- 
tion to  kidney  disease. 
It  is  sometimes  termed 
Peptonuria  ;  but  the  true 
peptone  of  Kiihne  is 
rarely,  if  ever,  found. 


1008.  Nucleo-proteid 

Of  little  clinical  import. 
It  is  almost  identical  with 
mucin  (see  953). 

*  Albuminuria,  Febrile 
„  Postural 

Cystitis 
Jaundice 
Leukaemia 
Nephritis,  Acute 

Arsenic,  naphthol,  and  mer- 
cury will  produce  it. 


1009.  Fibrinuria 

Orange-coloured  urine  which 
coagulates  on  standing. 

Haematuria 

esp.  after  cantharides 
Nephritis  (x) 

without  blood 

Villous  Growth 

The  urine  in  Chyluria  also 
coagulates  on  standing 

tj  2  1006-1009 


292 


UKINE 


1010.  Mucus 

Mucin  may  be  mistaken  for 
albumen.  It  yields  a 
precipitate  with  acetic 
acid,  a  5  per  cent,  dilution 
of  which  should  be  added 
to  an  equal  quantity  of 
the  urine,  cold.  Urinary 
mucin  is  largely  made  up 
of   nucleo-proteid  (1008). 

Cancer  of  Bladder 
Cystitis 
Oxaluria 
Prostatic  Disease 
threads 

Pyelitis,  Acute 
Spinal  Injuries  and  Diseases 
♦Tuberculosis  of  Bladder  or 
Kidney 

In  small  quantities  mucus, 
at  least  in  females,  is  a 
normal  constituent ;  in 
large  quantities  it  is 
chiefly  noticeable  by  its 
cloudiness  in  alkaline 
urine. 

Pus  (see  1047) 


1011.  Kreatinin  Diminished 

Anaemia 
*  Convalescence  from  Fevers 
*Marasmus 
Progressive  Muscular  Atro- 
phy 
Pseudo-hypertrophic     Para- 
lysis 
Splenic  Enlargement 
Tuberculosis 

Kreatinin  is  increased  by 
muscular  exercise  and  by 
fevers.  Fortunately  these 
conditions  are  not  associ- 
ated with  glycosuria  (see 
949). 


1012.  Sugar   (Glycosuria) 
For  tests  see  949. 

Acromegaly 
Alcoholism 

or  a  single  draught  (x) 

Apoplexy 
Boils 
a  little 

Calculus,  Pancreatic 
after  paroxysm 

Cancer  of  Pancreas 
Carbuncles 
a  little 

Cerebral  Tumours 

Chronic   Pancreatitis 

if    islands    of    Langerhans 
are  affected 

Cirrhosis  of  Liver  (x) 
Concussion  of  Brain 
Convalescence  from  Fevers 
♦Diabetes  Mellitus 
Diabetes,   '  Renal ' 
unaffected  by  diet 

Disseminated    Sclerosis    (x) 
Enterocolitis  (x) 
Exophthalmic  Goitre 
Fractured  Skull 
a  little 

Gouty  Glycosuria 
Hooping  Cough 
Hydrophobia  (x) 
Hypopituitarism 
Locomotor  Ataxy  (x) 
Medulla,  Lesion  of 
Melancholia 
Meningitis,  Tuberculous 

37  per  cent,  of  cases ; 
rarely  present  in  other 
forms 

Neurasthenia 

1010- 1C 12 


URINE 


293 


Sugar — continued 
Obesity  (x) 

Pancreatic  Haemorrhage 
Pancreatitis,  Catarrhal 
Pineal  Gland  Lesions 
Phosphorus-poisoning 
Portal  Obstruction 
transient — urina  cibi  only 

Rabies 

Rheumatoid  Arthritis 
Starvation 
Tetany 
Tonsillitis 
transient 

Ulcer  of  Stomach  (x) 

Sugar  is  also  found  after 
chloroform  or  ether  inha- 
lation, after  eating  largely 
of  grape  sugar,  in  car- 
bonic-acid-poisoning and 
after  nitrite  of  amyl, 
thyroidin,  adrenalin, 
atropin,  curare,  morphia, 
strychnin,  phloridzin, 
acetone,  uranium,  and 
copaiba. 

In  non-diabetic  glycosuria, 
the  urine  secreted  during 
the  night  is  said  to  con- 
tain no  sugar. 

1013.  Laevulosuria 

This  is  suggestive  of — 
Hepatic  Disease 


1014.  Pentose 

Found  normally  in  some 
beer  drinkers.  It  is  of 
no  clinical  importance 
(950). 


Diabetes 
Morphinomania 
Pancreatic  Disease 


1015.  Lactose 

Does  not  ferment  yeast 

Lactation 
Mollities  Ossium 
Puerperal  State 

1016.  Inosite  ( Muscle Jsu  gar) 
Copious  Draughts  of  Water 

*Diabetes  Insipidus 
Nephritis,  Chronic 
Tumour  of  Fourth  Ventricle 

1017.  ACIDOSIS 

Acetone,  diacetic  acid, 
and  the  /3-oxybutyric  acid 
from  which  they  are 
derived  are  grouped  to- 
gether as  Acidosis  or 
Ketonuria.  This  is  found, 
in  general,  when  in- 
sufficient carbohydrate 
food  is  absorbed  as  well 
as  in  deficient  oxygena- 
tion. 

1018.  Acetone 

Broncho-Pneumonia 
Cancer 

Cerebral  Disease 
Cyclical  Vomiting 
*Diabetes 

esp.  diabetic  coma 

Dilated  Stomach 

Diphtheria 

Exophthalmic  Goitre 

Fevers 

Gastric  Ulcer 

Gastro-Enteritis 

Hyperpyrexia 

Inanition 

Liver,  Cirrhosis  of 

Locomotor  Ataxy 

Melancholia 

1012-1018 


294 


URINE 


Acetone — continued 

Morphinism 

Mountain  Sickness 

Nephritis 

Pneumonia 

Pregnancy 

Salicism 

Septicaemia 

Tuberculosis,  hi. 

Uraemia 

Also    in    prolonged    rectal 
feeding  or  starvation  and 
after     administration     of 
ether  or  chloroform. 
(Tests,  966) 

1019.  Diacetic  Acid 

This  is  formed  by  the  oxida- 
tion of  /3-oxybutyric  acid 
(967). 
Cirrhosis  of  Liver 
*Diabetes 
Fasting 
Fevers 

Meat  Diet,  Exclusive 
Morphinism 

1020.  Urobilin  in  Excess 

Addison's  Disease 

Anaemia,  Haemolytic 

Carcinoma 

Cerebral  Haemorrhage 

Chloroform  Inhalation 
*  Cirrhosis  of  Liver 

Congestion  of  Liver 

Fevers 

Haematocele 
*Haemoglobinuria,    Paroxys- 

Infarctions  [mal 

Multiple  Neuritis 

Pernicious  Anaemia 

Pregnancy,  Extra- uterine 

Scurvy 


Bile  Colouring-matter 

(See  Jaundice,  392) 


1021.  Bile  Acids 

Of  no  special  clinical  im- 
portance. Oliver's  test 
is  now  used. 


Jaundice  (392) 


1022.  Indican 

Normally,  it  should  be 
arrested  in  the  liver.  Its 
presence  therefore  in  the 
urine  may  point  to  hepatic 
insufficiency. 

Addison's  Disease 

Appendicitis 

Bronchitis,  Putrid 
*Cancer  of  Stomach  or  Liver 

Cerebro -spinal  Meningitis 

Cholera 

Constipation  (x) 

Empyema,  Fetid 

Gangrene  of  Lung 

Hypochlorhydria 

Lymphatic  Growths 
Obstruction  in  Small  Intes- 
tine 

Pancreatic  Disease 

Peritonitis,  Suppurative 

Pernicious  Anaemia 

Phthisis 

Tabes  mesenterica 
*Toxaemia,  Intestinal 

It  is  produced  in  ex- 
cess by  residence  in 
the  tropics  and  by  the 
action  of  turpentine, 
bitter  almonds,  and  nux 
vomica,  also  by  a  red- 
meat  diet. 

1018-1022 


URINE 


295 


1023.  Urea  Increased 

The  normal  total  is  about 
33  grammes. 

Ague  (warm  stage) 

Azoturia 

Cerebro-spinal  Meningitis 

Chorea 

Diabetes 

„         Insipidus 
Enteric  Fever 
Fevers,  n. 

commencing  defervescence 

Leukaemia 
Paralysis  Agitans 
Pernicious  Anaemia 
Pneumonia,  Acute 
Pyrexia  (295) 
Rheumatism,  Acute 
Scarlatina 

*„.*  Other  causes  are  excess  of 
food ;  bathing,  exercise, 
electricity,  and  the  follow- 
ing drugs :  ammonium 
salts,  arsenic,  antimony, 
codeia,  phosphorus,  sul- 
phuric acid,  thyroid  gland 
and  large  doses  of  quinine. 

1024.  Urea  Diminished 

Acute  Yellow  Atrophy 
absent  at  termination 

Addison's  Disease 

Amyloid 

Anaemia 

Cancer  of  Liver,  m. 

Cirrhosis  of  Liver 

Congestion  of   Kidney, 
Passive 

Contracted  Kidney 

General  Paralysis 

Lead-poisoning 

Melancholia 


Nephritis,  Chronic 

Osteomalacia 

Phthisis 

Pyorrhoea  Alveolaris 

Rheumatism,  Chronic 

Rickets 

Starvation 

Syphilis 

Uraemia 

Also  phosphorus-poisoning 
and  quinine  even  in 
small  doses 


1025.  Uric  Acid  Increased 

The  normal  total  is  about 
7  to  10  grains  (0-4  to  0'7 
gramme). 

Diabetes 

Fevers 

Gout,  Chronic 

Heart  Diseases 

Infantile  Colic 
^Leukaemia 

Lithaemia 

Liver  Affections 

Lung  Diseases 

Pernicious  Anaemia 

Pneumonia 

Rheumatism 

The  statements  of  investi- 
gators are  very  contra- 
dictory, but,  in  general, 
uric  acid  is  increased 
either  by  deficient  oxi- 
dation (fevers,  heart  and 
lung  diseases),  or  by 
food  containing  much 
nucleolin,especially  sweet- 
breads. Its  excess  in 
the  blood  is  not  neces- 
sarily accompanied  by  an 
excess  in  the  urine.  In- 
deed, the  reverse  may 
be  the  case. 

1023-1025 


296 


URINE 


1026.  Uric  Acid  Diminished 

Anaemia 

Diabetes  Insipidus 

Gouty  Paroxsym  (?) 

Kidney  Disease,  Advanced 

Lead-poisoning 

Quinism 

Rickets 

Scurvy 

According  to  some,  the 
quantity  is  increased  in 
the  gouty  paroxysm. 

1027.  Hippuric  Acid 

Chorea 

Diabetes  Mellitus 
Pyrexia  (295) 

It  occurs  also  after  taking 
benzoic  acid  or  fruit, 
such  as  cranberries,  mul- 
berries, etc. 

1028.  Phosphates  Increased 

The  amount  of  phosphatic 
sediment  is  no  indication 
of  the  quantity  of  phos- 
phates in  the  urine,  for 
the  phosphates  of  the 
alkalies,  which  constitute 
three  -  fourths  of  the 
total,  are  readily  soluble. 

Anaemia 
Animal  Diet 

Cerebro -spinal  Meningitis 
Chorea 

Diabetes  Insipidus 
*Diabetes  '  Phosphatic  ' 
sugar-free 

Dilated  Stomach 
Encephalitis 
Gastric  Catarrh 
Henoch's  Purpura 
Leukaemia 


Mania,  Acute 
Mollities  Ossium 
Neurasthenia 
Pleurisy 
Pneumonia,  in. 
Pyrexia  (295) 
Rheumatism,  Acute 
Rickets 
Tumours  of  Brain 

In  general,  diseases  of  bones, 
brain,  or  spinal  cord. 

1029.  Phosphates  Diminished 

Acute  Yellow  Atrophy 
Addison's  Disease 
Ague 

during  attack 

Enteric  Fever 

Nephritis 

Phthisis 

Rheumatism,  Chronic 

Typhus 

Vegetable  Diet 

1030.  Chlorides  Increased 

Normal    total    of     chlorine 
10  to  15  grammes. 

Ague 
during  fit 

Convalescence    from    Pneu- 
monia and  Fevers 
Copious  Drinks 
*Diabetes  Insipidus 
Epilepsy 

General  Paralysis 
Malaria 

Myelitis,  Acute 
Prurigo 

Rapid  Absorption  of  Dropsi- 
cal Effusions 
Rotheln 

1026-1030 


URINE 


297 


1031.  Chlorides  Diminished 
Acute  Yellow  Atrophy 

absent  at  last 

Anaemia 
Anasarca 

Cancer  of  Stomach 
Cerebro -spinal  Meningitis 
Chorea 
Diarrhoea 
Dyspepsia 
Enteric  Fever 
Haemorrhage 
Inanition 

Kidney,  Congestion  of 
Lead-poisoning 
Melancholia 
Multiple  Myoma 
Nephritis 

Phosphorus-poisoning 
*Pneumonia,  Acute 
Pyrexia  (295) 
Rheumatism,  Acute 
Rickets 
Scarlatina 
Serous  Effusions 

1032.  Sulphates  Increased 

Normal  total  2  grammes. 

Cancer  of  Pylorus 

Diabetes 

,,        Insipidus 

Fevers 

Pneumonia 

Progressive  Muscular  Atro- 
phy 

1033.  Ehrlich'sDiazo-reaction 

This  is  an  indication  of 
abnormal  protein  meta- 
bolism. 

For  method  of  testing  see 
965. 


Abscess,  Cold 
Actinomycosis 
Alcoholism,  Chronic 
Cachexias,     Cancerous    and 

Other 
Diphtheria 
*Enteric  Fever 

81  per  cent,  of  cases 
Erysipelas 
Heart  Disease,  Old 
Hepatitis,  Chronic 
Influenza 
Leukaemia 
Malaria 
Malta  Fever,  i. 
Marasmus,  Senile 
Measles 

72  per  cent. 

Paratyphoid 
Pneumonia 

10  per  cent. 
Pulmonary  Tuberculosis 

14  per  cent. 
Scarlatina 
Septicaemia 
Typhus 

5  per  cent. 

It  also  occurs  after  taking 
opium  and  tar  products, 
but  is  absent  in  simple 
meningitis  and  in  rotheln. 


1034.  Egg  Yellow  Reaction 

A  yellow  foam  showing 
itself  with  Ehrlich's  re- 
agent before  the  addition 
of  ammonia  is  said  to  be 
characteristic  of  the  crisis 
of:— 

Acute  Pneumonia 

1031-1034 


298 


URINE 


1035.  Phloridzin  Test 

Thirty  minutes  after  the 
subcutaneous  injection  of 
15  minims  of  0'5  per  cent, 
solution,  sugar  should  bo 
detected  during  a  period  of 
four  hours.  Otherwise, 
there  is 
Renal  Inadequacy 

1036.  Bouchard's  Coefficient 

The  ratio  between  the 
nitrogen  of  urea  and  the 
total  nitrogen  — normally 
84  per  cent.  It  is  high 
in  accelerated  metabolism 
and  notably  in  tuber- 
culosis in  all  stages  ;  low 
in  diseases  with  slow 
metabolism. 

1037.  Cammidge's  C.  Reaction 

Before  testing,  alcohol  and 
sugar  must  be  eliminated. 

Gallstone  (x) 
Pancreas,  Cancer  of 
*Pancreatitis 

Twenty-five  per  cent,  of 
cases  of  pancreatic  disease, 
or  only  when  inflamma- 
tion is  superadded. 

1038.  Diastase 

A  small  quantity  is  normally 
present.         An     increase 
shows  : — 
Pancreatic  Insufficiency 
Pulmonary  Tuberculosis 


1039.  Freezing  Point  A 

The  normal  freezing  point 
is  -1-3°  to  -2-2°  C.  A 
raised  index  implies  renal 
inadequacy. 

Inflammatory   Kidney  Dis- 
eases 
not  more  than  —  1°  C. 


1040.  Faeces    passed    through 
Urethra 

Abscess,  Appendicular,  Pro- 
static, Pelvic,  or  Rectal 
Cancer  of  Bladder 
„     of  Rectum 
,,     of  Uterus 
Colon  Diverticulum, 

Perforated  (x) 
Recto-vesical  Fistula 

1041.  Pneumaturia 

Derived  from  external  or 
intestinal  gas  or  from  that 
produced  in  the  bladder 
by  B.  lactis  aerogenes, 
B.  aerogenes  capsulatus, 
B.  Coli,  or  yeast. 

Abscess 

Carcinoma,  Adjacent 
Diabetes 

Foul  Catheterism 
Recto-vesical  Fistula 
fsecal  odour 


1035-1041 


URINE 


299 


1042.  URINARY  DEPOSITS 


1043.  SEDIMENTS 

These  are  best  obtained  by 
the  centrifuge  ;  if  the 
conical  glass  is  employed, 
a  little  camphor  should 
be  added  to  prevent  de- 
composition. Urates  of 
soda  and  potash  are 
readily  soluble  on  heating. 

Soluble  in  Acetic  Acid 
Ammonium  Urate 
Calcium  Carbonate 

with  effervescence 
Phosphates,  Earthy 

no  effervescence 


Insoluble  in  Acetic  Acid 

Calcium 

„       Sulphate 
Leucin 
Cystin 
Tyrosin 
Uric  Acid 
Xanthin 

Soluble  in  Hydrochloric  Acid 

Calcium  Oxalate 

Leucin 

Cystin 

Tyrosin 

Xanthin 

***  The  last  three  are  soluble 
in  ammonia. 

Insoluble  in  Hydrochloric  Acid 

Calcium  Sulphate 
Uric  Acid 


1044.  Brickdust  Sediment 
Chiefly  urate  of  soda.     The 

pinkish  colour  is  due 
to  uroerythrin.  It  does 
not  necessarily  mean  in- 
creased excretion  of  uric 
acid.     Tests,  see  1045. 

Ague  (sweating  stage) 

Cancer  of  Liver 

Congestion  of  Kidney 
*Constipation 

Cyanotic    Liver 

Dilatation  of  Stomach 

Dysentery 

Dyspepsia 

Emphysema 
*Faecal  Accumulation 

Gastritis,  Acute  or  Chronic 

Gout 

Heart  Disease 

failing  compensation 

Hyperidrosis   (316) 
*Lithaemia 

Pneumonia,  Acute 

Pyrexia  (295) 

Rheumatism,  Acute 

Sweating 

from  any  cause 

1045.  White  Sediment 

If  soluble  on  heating  and 
in  liquor  potassae,  the 
deposit  consists  of  urates 
without  the  adventitious 
uroerythrin.  This  form 
takes  the  place  of  the 
above  in  children  and  in 
some  adults.  If  insoluble 
on  heating,  but  soluble 
in  liquor  potassse,  the 
sediment  consists  of  phos- 
phates. 

1042-1045 


300 


URINE 


o  f:6 


<£? 


m^T 


Uric   Acid 


cQr 


Urate    of    Ammonia 


,.'l!lffil!!!li!ii 


Trirtle    Phosphates 


Nitrate  ot    Urea 


Oxalate    of    Lime      («) 


Oxalate    of  Lime    (b) 


Fig.  8 — Urinary  Crystals 


URINE 


301 


1046.  CALCULI 

These  are  very  often  of 
mixed  composition.  Cal- 
culi composed  of  uric  acid 
are  hard  smooth  and 
reddish ;  of  urates,  soft 
friable  and  light  yellow  ; 
of  oxalates,  hard  nodular 
and  dark  ('  mulberry  cal- 
culus ') ;  of  phosphates, 
chalky  and  friable ;  of 
carbonate  of  lime,  round 
white  and  hard;  of 
cystin,  soft  crystalline 
and  yellowish  green  ;  of 
xanthin,  hard  smooth  and 
cinnamon  coloured. 

Burn  on  Platinum  Foil : — 

No  Residue 
Cholestearin 
Cystin 
Uric  Acid 
Xanthin 

Residue 

Calcium  Salts 

Magnesium  Salts 

%*  Treat     with     acids     as     in 
sediment  tests. 


Murexide  Test 

Heat  a  few  crystals  on  a 
porcelain  dish  with  dilute 
nitric  acid.  The  reddish 
residue  turns  purple  with 
a  little  dilute  ammonia. 

Uric  Acid 


Cystin  Test 

The  powder  is  digested  with 
ammonia,  filtered,  and 
evaporated  in  a  watch 
glass ;  crystallisation  in 
hexagonal  plates  indi- 
cates : — 


Cystin 


Cholestearin  Test 

Cholestearin  dissolves  in 
ether,  leaving  rhombic 
plates  on  evaporation. 


1046 


302 


URINE 


MICROSCOPY 


1047.  Pus-cells  (Pyuria) 

Abscess,  Acetabular,  Appen- 
dicular, Dermoid,  Ischio- 
rectal, Ovarian,  Pelvic, 
Perinaeal,  Perinephric, 
Prostatic,  Psoas,  Rectal, 
Renal,  or  Salpingitic 
bursting  into  urinary  tract 

Calculus,  Vesical  Renal    or 

Ureteral 
Carcinoma 

involving  urinary  tract 

Cystic  Kidney,  ni. 
Cystitis 
Gleet 

*Gonorrhoea 
Leucorrhcea 
Pyelitis 
Pyelonephritis 
Pyonephrosis 
intermittent 

Stricture  of  Urethra 
Suppurative  Nephritis 
Tuberculous  Bladder 
Tuberculous  Kidney 
urine  acid 

Ulcer  of  Bladder 
Ureteritis 
Urethritis 
Villous  Growth 

When  the  urine  is  acid  and, 
apart  from  blood,  con- 
tains very  little  albumen, 
the  pus  probably  comes 
from  the  kidney. 

Exclude  extraneous  pus, 
such  as  that  from  leu- 
corrhcea. 


Blood-cells 

(As  in  Hcematuria,  1000) 

1048.  Growth  Particles 

The  deposit  must  be  centri- 
fuged. 

Cancer  of  Urinary  Tract 

1049.  Epithelium,  Excess  of 

It  is  normal  in  moderate 
quantity.  There  are  three 
varieties  in  the  urinary 
tract.  Squamous  :  in  the 
meatus,  the  vagina,  the 
bladder,  and  the  pelvis 
of  the  kidney.  Columnar  : 
in  the  urethra  and  ureters. 
Spheroidal  or,  by  pressure, 
Polygonal :  in  the  tubules 
of  kidney.  This  last  is 
the  important  kind. 

Cystitis 

Nephritis,  Acute 
Pyelitis 

Renal  Calculus 
Scarlatina 
Urethritis 


1050.  Fat-globules 

Alcoholism,  Chronic 
Chyluria  (996) 
Diabetes 
*Fat  Embolism 
recent  fracture 

Patty  Food 
Leukaemia 
Malingering 
*Nephritis,  Chronic 
large  pale  kidney 

Obesity 

1047-1050 


URINE 


303 


Fat-globules — continued 
Pancreatic  Disease 
Phosphorus-poisoning 
Pyonephrosis 
Suppuration,  Prolonged 

Exclude  oil  from  a  catheter. 
The  globules  are  often 
seen  in  persons  taking 
cod-liver-oil. 

1051.  Elastic  Fibres 

Tuberculous      Bladder      or 

Kidney 
Ulceration  of  Urinary  Tract 
(See  Sputa,  1140) 

1052.  Pigment 
Malaria 

1053.  Oxalates 

Octahedric  or  dumbbell 
crystals,  due,  in  general,to 
diseases  of  imperfect  oxi- 
dation, as  in  heart  and 
lung  affections.  Oxa- 
lates also  appear  after 
eating  gooseberries.,  figs, 
rhubarb,  cabbage,  the 
pulses,  beetroot,  etc.,  and 
even  after  drinking  tea, 
coffee,  or  cocoa. 

Atony  of  Stomach 

Bronchitis,   Chronic 

Diabetes 

Digestion,  Defective   Carbo- 
hydrate 

Gout 

Jaundice 

Leukaemia 

Lithaemia 

Neurasthenia 

Obesity 

Pancreatic  Disease 
63  per  cent. 


Paroxysmal      Haemoglobin  ■ 

uria 
Phthisis 
Pneumonia 
Spermatorrhoea 

Phosphates     (Prismatic     Crys- 
tals (see  1028) 

1054.  Cholestearin 

Cystitis,  Chronic 

Dyspepsia 

Eatty  Kidney 

Filariasis 

Hydatids  of  Kidney 

Hydronephrosis 

Kidney,  Cystic 

Pyonephrosis 

1055.  Leucin  and  Tyrosin 

In  acid  urine  only. 
*Acute  Yellow  Atrophy 
Cirrhosis  of  Liver 
Enteric  Fever,  Severe 
Pernicious  Anaemia 
Phosphorus -poisoning  (x) 
Tuberculosis,  Acute 
Typhic  State  (62) 
Variola 

1056.  Cystine  Crystals 

Cystic  Calculus 
Intestinal  Putrefaction 

1057.  Uric  Acid  Crystals 

Urates  in  very  acid  urine. 

1058.  Spermatozoa 

Normal  after  coitus. 

Masturbation 
Rectum,  Loaded 
Spermatorrhoea 

1051-1058 


304 


URINE 


1059.  Gonococci 

Gonorrhoea 

1060.  Bacilli,  etc. 

The  urine,  which  is  often 
clear  and  acid,  must  be 
drawn  off  and  a  culture 
made.  Some  non-patho- 
genic organisms  are  nor- 
mally present. 

B.  coli  communis 

cystitis,  pyelitis,  prostatitis, 
etc. 

B.  Klebs-Loeffler 

30  per  cent,  of  diphtheria 
cases 

B.  paratypbosus 
B.  proteus 
B.  pyocyaneus 
B.   smegmse 
B.  tuberculosis 

iubercle  of  urinary  tract 


B.  typhosus 
enteric  (25  per  cent.) 

Diplococcus  of  Pneumonia 
Micrococcus  Melitensis 
Pneumobacillus     of     Fried  - 

lander 
Pnsumococcus 
Staphylococcus  pyogenes 
Streptococcus  pyogenes 
(See  Bacteria,  1495) 

1061.  Torula  cerevisiae 

Diabetes 
Glycosuria 

1062.  Hooklets 

Hydatids 

1063.  Eggshells     and      Flask- 
shaped  Bodies 

Distoma  Haematobium 


1059-1063 


URINE 


305 


1064.   CASTS 


Fig.  9 — Casts. 
a,  hyaline;    b,  granular  ;    c,  epithelial ;    d,  fatty ;   e,  blood. 

The  centrifuge  should  be  used.  A  few  isolated  casts  may  usually 
be  ignored.  They  are  sometimes  unexpectedly  absent ;  this  is 
believed  to  be  due  to  bacterial  action  (B.  coli).  Further,  if  urine 
is  allowed  to  stand  too  long,  casts  will  sometimes  disappear.  Mixed 
casts  occur. 


1065.  Hyaline  or  Fibrinous 

A  few  are  often  present 
normally.  They  can  be 
demonstrated  in  doubtful 
cases  with  hematoxylin. 

Amyloid  Kidney 
Diabetes 
Diphtheria 
Displaced  Heart 
Intermittent  Albuminuria 
Jaundice 
yellowish 

Mitral  Disease 
*Nephritis,  Acute 

both  small  and  large 
*Nephritis,  Chronic 
large — numerous 
Pancreatitis,  Acute 


Polycythemia,      Splenome- 

galic 
Pregnancy 
Pyrexia  (295) 

1066.  Granular  Casts 

Amyloid  Kidney 
Cirrhosis  of  Kidney 
Cyanotic  Kidney  (x) 
*2sephritis,  Chronic 
late 

Polycythsemia,      Splenome- 
galic 

1067.  Epithelial  Casts 
Action  of  Irritants 
Congestion,  Passive 
Jaundice 

*  1064-1067 


306 


URINE 


Epithelial  Casts — continued 
*Nephritis,  Acute 
'  cloudy  swelling  ' 
Weil's  Disease 

1088.  Fatty  Casts 

Fatty     Degeneration      of 

Kidney 

or  of  a  portion  of  it 
Nephritis,  Chronic 

large  pale  kidney 

1069.  Blood  Casts 
Cancer  of  Kidney 
Congestion   of   Kidney, 

Passive 
Cystic  Disease  of  Kidney 
Embolism  of  Kidney 
Hyperemia  of  Kidney 
Nephritis,  Acute 
Renal  Calculus 

Also  the  external  or  internal 
use  of  cantharides  or 
turpentine. 

1070.  Pus  Casts 

Abscess  of  Kidney 

Pyelitis 

Pyelonephritis 


1071.  Amyloid  or  Waxy  Casts 

Nephritis,  Chronic 

Not  amyloid  disease.  Of 
little  significance. 

1072.  Bacterial  Casts 

Pyelonephritis 

secondary  to  crystal-irrita- 
tion or  septic  infarcts 

1073.  Testicle  Casts 

Spermatorrhoea 

1074.  Cylindroids 

These  are  thinner  and  often 
flatter  than  casts.  They 
are  composed  of  mucus 
and  are  of  no  diagnostic 
importance.  At  most 
they  indicate : — 

Renal  Irritation 

1075.  Prostatic  Threads 

These  are  just  visible  to 
the  naked  eye. 

Chr.  Prostatitis 
esp.  gonorrheal 

1076.  v.  Jakseh's  Spirals 

Renal  Calculus 


1067-1076 


BOWELS 


307 


1077.  BOWELS,  STATE  OF 

The  contents  of  the  small  intestine  should  travel  at  the  rate  of 
about  one  inch  per  minute  ;  but  the  recent  experiments  of  Holz- 
knecht  upon  a  thousand  human  beings  show  that  '  peristalsis ' 
( ?  syphonage)  in  the  colon  may  occupy  less  than  a  minute.  Syphonage 
may,  however,  be  quite  slow. 

A  small  motion  may  appear  once  after  obstruction  in  the  bowel 
has  been  absolute,  but  no  flatus  will  be  passed. 


1078.  Constipation     and     Ob- 
struction 

Constipation  is  said  to  be 
more  frequent  in  women 
because  they  take  less 
exercise.  I  suggest  also 
that  owing  to  the  thoracic 
character  of  their  breath- 
ing, they  miss  a  good 
natural  form  of  massage 
produced  by  the  rhythmic 
descent  of  the  diaphragm. 
One  form  of  constipation 
accompanies  abdominal 
pain  and  ceases  with  the 
relief  of  this. 

Abdominal  Aneurysm 

Tumours  (1615) 

Acute  Yellow  Atrophy 

Adhesions 

Ague 

*Amenorrhoea 
*Anaemia 

Apoplexy.  Spinal 

Appendicitis 

Ascites 
*  Atony  of  Bowel  or  Stomach 

Atrophy,  Senile 

Cancer  of  Bowel,  Kidney, 
Pancreas,  Stomach,  Uterus, 
or  Rectum 

Cirrhosis  of  Stomach 

Compression  of  Cord 

Concretions  (1102) 


Cretinism 
*Diabetes 
Dilatation    of    Colon,    Idio- 
pathic 
,,  of  Stomach 

Diverticulitis 
Duodenal  Catarrh 
Embolism  of  Sup.  Mesenteric 

Artery 
Enteric  (1st  week) 
Enteroptosis 
Erysipelas 
Fissure 
Gastritis 
Gout 

HEemorrhage,    Subperinaeal 
Haemorrhoids 
Hernia,  Strangulated 
Hyperidrosis 
Hypertrophy  of  Pylorus 
Hysteria 
Influenza 
Insanity 
Intussusception 
Jaundice  (392) 
Kinked  Bowel 
Lactation,  Prolonged 
*Lead-poisoning 
Lithsemia 
Locomotor  Ataxy 
Meningitis 
Mucous  Colitis 
x  2  1077-1078 


308 


BOWELS 


Constipation    and  Obstruc- 
tion— continued 

Myelitis 

Neurasthenia 

Ovarian  Tumours 

Paralysis,  Acute  Ascending 
,,         Intestinal 
,,         of  Diaphragm 

Paraplegia 

Pelvic  Cellulitis 

Peritoneal  Adhesions 

Peritonitis 

except     the     pneumococcic 
form 

Polypus,  Intestinal 

Prolapse  at  Sigmoid  Flexure 

Prolapsus  Uteri 

Prostate,  Enlarged 

Prostatitis 

Pyrexia 

Retroflexion  and  Retrover- 
sion 

Scurvy 

Scybala 

Stricture  of  Rectum,  Bowel, 
Pylorus,  or  (Esophagus 

Tetanus 

Tetany 

Tubal  Dilatation 
„      Gestation 

Tumour  of  Brain 

Ulcer  of  Stomach 

Volvulus 

Constipation  is  frequently 
due  to  diet — such  as 
excess  of  eggs  or  milk  or 
deficiency  of  liquids  or 
vegetables.  It  often  ac- 
companies a  visit  to  the 
seaside,  especially  where 
the  soil  is  chalky.   A 


1079.  Diarrhoea 

Diarrhoea  is  very  commonly 
due  to  the  presence  of 
some  irritating  substance 
in  the  bowel.  The  stream 
poured  out  reflexly  from 
the  mucous  membrane  is 
apt,  however,  to  start  at 
or  below  the  point  of  irri- 
tation. Drugs,  therefore, 
are  indicated  which  will 
pour  out  a  stream  from 
above  until  the  cause  is 
removed. 

Achylia  Gastrica 

Addison's  Disease 

periodic 
Amyloid  Disease 
Appendicitis 

in  children  and  sometimes 
initially  in  adults 

Botulism 

Cancer  of  Liver  or  Colon 

„      of  Rectum,  i. 

morning  diarrhoea 
Cholera 
Cirrhosis  of  Kidney 

„        of  Liver  (x) 
Colitis,  Ulcerative 
Dilated  Stomach 

morning  diarrhoea 
Dysentery 
Empyema 

Endocarditis,  Ulcerative 
Enteric  Fever 
Enteritis 

Gangrene  of  Lung 
Gastric  Irritation 
Gastritis,  Erythematous 
Gastro -Enteritis 

in  children 
Glanders,  n. 
Hepatitis,  Acute 
Hydrocephalus,  Spurious 
1078-1079 


BOWELS 


309 


Diarrhcea — continued 

Intussusception 

Leukaemia 

Locomotor  Ataxy 
gastric  crisis 

Lymphadenoma  (x) 

Metritis,  Acute 

Pancreatitis 

Paralysis  of  Solar  Plexus 

Periarteritis  Nodesa 

Peritonitis,  Pneumococcic 

Pernicious  Anaemia 
periodic 

Phthisis,  H. 

Poisoning  by  Arsenic,  Anti- 
mony, Mushrooms,  etc. 

Pseudo- Leukaemia  Infan- 

Ptomainism  [turn 

Puerperal  Fever 

Pyaemia 
♦Retained  Scybala 

Rickets 

Septicaemia 

Sprue 

Syphilitic  Liver 

Tabes  mesenterica 

Trichinosis 

Tuberculosis,  Acute 

Ulceration  of  Bowel 

Uraemia 

1080.  Flatulence    and    Borbo- 
rygmi 

Borborygmi,  the  internal 
abdominal  noises  so  com- 
monly heard,  are  due  to 
exaggerated  '  segmenta- 
tion movements  '  in  the 
bowel. 

Abdominal  '  Angina  ' 
„  Cancer 

„  Tumours  (1615) 


♦Aerophagia  Nervosa 

Cirrhosis  of  Liver 
♦Constipation  (1078) 

Cyanotic  Liver 

Dilatation  of  Stomach 

Dysentery 

Dyspepsia 

Emphysema 

Enteritis 

Faecal  Accumulation 

Gastritis 

Heart  Disease 

Hypochondriasis 
♦Hysteria 

Intestinal  Obstruction 

Jaundice  (392) 

Lithaemia 

Nervousness 

Neurasthenia 

QCsophago-tracheal  Fistula 

Tight  Lacing 

Tympanites  (1700) 

The  pulses,  earthed  vege- 
tables and  stewed  fruits 
are  common  causes. 

Meteorism,  see  1700 

1081.  Tenesmus  (Frequent  and 
fruitless  straining) 
Adenoma,  Rectal 
Appendicitis  (x) 
Calculus,  Vesical 
Cancer  of  Colon  Desc. 

,,     of  Rectum 
Colitis 
Concretions 
Diarrhcea,  hi. 
♦Dysentery 
Fissure  of  Anus 
Fistula 

Foreign  Body  in  Rectum 
Haemorrhoids 

1079-1081 


310 


BOWELS 


Tenesmus — continued 
♦Intussusception,  Acute 

50  per  cent. 
Intussusception,  Chronic 

10  per  cent. 
Locomotor  Ataxy- 
rectal  crises 

Metritis,  Acute 

Ovarian  Cyst 

Poisoning  by  Arsenic,  Can- 
tharides,  and  other  irri- 
tants 

Polypus,  Rectal 

Proctitis 

Prostatic  Disease 

Retroflexion 
♦Scybala 

Stenosis  of  Rectum 

Volvulus 
15  per  cent. 

Ulcer,  Syphilitic 

„      ol  Colon 

„      of  Rectum,  Simple 
Worms 

1082.  Painful  Defsecation 

Cancer  of  Rectum 
scalding 

Cancer  of  Uterus 

Coccygodynia 

Colitis 

preceding  defsecation 

Condylomata 

Cystitis 

Fissure 
*Fistula 

Foreign  Body 
♦Haemorrhoids,  Inflamed 

Ischio- rectal  Abscess 

Metritis,  Acute 


Oophoritis 

Ovarian  Cyst 

Pelvic  Cellulitis 
,,       Peritonitis 

Periproctitis 
♦Prolapsus  Ani 

Prostatitis 

Retroflexed  Uterus 

Sacro-iliac  Disease 

Salpingitis 

Scybala,  Impacted 
♦Ulcer  of  Rectum 

1083.  Prolapsus  Ani 

Descent  of  the  bowel. 

Calculus,  Vesical 
♦Diarrhoea 

Haemorrhoids 

Hooping  Cough 
♦Phimosis 

Polypus,  Rectal 

Scybala 

Villous  Growth 

Vomiting 

Worms 

1084.  Rectal  Incontinence 

This  is  normal  in  infants 
until  the  tonicity  of  the 
sphincter  muscle  has  been 
acquired.  At  a  later  age, 
apart  from  occasional 
lapses,  it  is  due  to  in- 
adequate action  of  the 
sphincter. 

An  intermediate  condition, 
'  precipitate  defsecation,' 
occurs,  especially  in  asso- 
ciation with  spastic 
paralysis. 

Apoplexy 
♦Cancer  of  Rectum,  ii. 
Cholera 

1081-1084 


BOWELS 


311 


Rectal    Incontinence — con- 
tinued 

Chorea,  Severe 
♦Coma  (64) 

Convulsions 

Cord,  Compression  of 
„      Injuries  to 

Diarrhoea  (1079) 

Disseminated  Sclerosis 
esp.  in  sacral  form 

Dysentery 

Enteric 

Epilepsy,  n. 

Erb's  Spinal  Paralysis 

Fissure  of  Anus  (x) 

Fistula 

Haematomyelia 

Hooping  Cough  (x) 

Leptomeningitis,  Spinal,  n. 

Locomotor  Ataxy,  n. 

Myelitis 


Paralysis,  Diphtheritic 

„         General,     of     In- 
sane, n. 
Paraplegia 

Perinseum,  Lacerated 

Poisoning  by  Strychnine  or 
Prussic  Acid 

Procidentia  Recti 

Shock 

Spastic  Paraplegia 

Spinal  Meningitis,  n. 

,,      Meningeal      Haemor- 
rhage 

Sunstroke 

Syringomyelia 

Tetanus 
*Typhic  State  (62) 

Uraemia 

Worms  (x) 


1084 


312 


STOOLS 


1085.  STOOLS 

The  normal  reaction  is  faintly  alkaline  or  neutral.  An  acid 
reaction  implies  carbohydrate  fermentation  ;  an  alkaline  one, 
putrefaction. 

For  purposes  of  examination  the  motion  should  be  passed  in 
a  dry  chamber,  without  admixture  of  urine  or  water,  and  without 
the  previous  administration  of  an  enema.  The  colour  of  the  adult's 
stool  is  due  chiefly  to  urobilin  ;  of  the  infant's,  to  bilirubin.  Before 
examining  for  minute  quantities  of  blood,  all  meat  products  must  be 
left  out  of  the  dietary  for  24  hours.  The  guaiacum  test  may  be 
used  (962).  Saundby's  test  is  as  follows.  Place  a  small  portion 
of  the  faeces  in  a  test-tube  with  10  drops  of  a  saturated  solution  of 
benzidin.  On  adding  30  drops  of  hydrogen  peroxide  (20  vols.) 
a  persistent  dark  blue  results.     But  there  are  many  sources  of  blood. 


1086.  Flattened  Faeces 
Cancer  of  Rectum 

*Ha3morrhoids 
Ischio -rectal  Abscess 
Prostate,  Enlarged 
Prolapsus  Uteri 
Rectal  Growths 
Retroflexion 
Spasm  of  Sphincter 
Stricture  of  Rectum 
Uterine  Fibroids 

1087.  Pipe-like  Faeces 
Intussusception 

*Prolapsus  Ani 
Scybala,  Pressure  of 
Spasm  of  Colon 
Starvation 
Stricture  of  Rectum 
Tenesmus 

1088.  Scybala    (Round    and 
Hard) 

Cancer  of  Bowel 
Constipation 
*Diabetes 
Dilatation  of  Stomach 


Dysentery 
Ingestion  of  Opium 
Retained  Fseces 
Ulcer  of  Stomach 

1089.  Pale    or    Putty-coloured 

Faeces 

Pale  stools  in  conjunction 
with  urine  of  natural 
colour  are  suggestive  of 
hepatic  insufficiency. 

Acute  Yellow  Atrophy,  I. 
Amyloid  Liver 
Anaemia  (385) 
Appendicitis 
Cancer  of  Duodenum 
Cancer  of  Liver 
Cirrhosis  of  Liver 
Cjeliac  Disease 

'  porridge   stools  ' 

Diarrhoea,  Irritative 
*Enteric  Fever 

like  pea-soup 
*  Jaundice  (392) 

esp/the  obstructive  variety 
Mucous  Colitis 

1085-1089 


STOOLS 


313 


Pale     or     Pcjtty-Coloured 

Faeces — continued 

Pancreatic  Disease 
'  orango   -juice ' 

Retention   of    Fseces,    Pro- 
longed 

Rickets 

Sprue 

drab    or   white — frothy 
Also      a    milk     or    vegetable 
diet. 

1090.  Green  (Infants) 
Cholera,  Spasmodic,  I. 

*Dentition 
Diarrhoea,    Irritative 
Enteritis,  Acute 
Hydrocephalus,  Spurious 
Methylene  Blue 
taken  internally 
Calomel  produces  '  chopped 
spinach '  stools. 

1091.  Slate  Colour 

Iron,  bismuth,  charcoal,  or 
manganese  internally. 

1092.  Serous  Stools 

Arsenic  -poisoning 
*  Asiatic  Cholera,  n. 
rice-water  stools 

Cancer  of  Rectum 
scalding 
*Cholera,  Sporadic 

Diarrhoea,  n. 

Dysentery 
^Enteritis,  Acute 

Mushroom-poisoning 

Sunstroke 


1093.  Offensive  Stools 

Decomposition  of  intestinal 
contents  —  often  from 
deficiency  of  bile.  Sour 
stools  are  said  to  bo  due 
to  the  bacteria  which 
thrive  on  sugars  and 
starches ;  foul  stools  to 
those  which  attack  pro- 
teids. 

Cancer  of  Colon  or  Rectum 

Chloroma 

Cholera  Infantum 

Coeliac  Disease 

Dysentery 

Enteric  Fever 

Enteritis,  Acute 

Erysipelas 

Gastritis,    Acute    Erythe- 
matous 

Glanders,  n. 

Jaundice  (392) 
*Retained  Fseces 

Rickets 

Scrofula 

Sulphur  (Internally) 

Syphilitic  Ulceration 

Ulcer  of  Colon 
*Undigested  Food 

Yellow  Atrophy,  Acute 

1094.  Pus  in  Stools 

Intestinal  digestion  soon 
alters  the  appearance  of 
pus  ;  that  from  an  ulcer 
is  usually  in  lumps. 

*Abscess 

rupturing    into    bowel — 
appendicular,  cholecystic, 
hepatic,  ischio -rectal, 

pelvic,  perinephric,    peri- 
proctic, psoas,  etc. 

Cancer  of  Colon 

„       of  Rectum 

1089-1094 


314 


STOOLS 


Pits  in  Stools — continued 
Dysentery 
Enteritis 
Fistula 

Proctitis,  Acute 
Ulcer  of  Rectum 

***  Exclude  pus  from  urethral 
or  vaginal  discharges. 


1095.  Tarry  Stools  (Melaena) 

Haemorrhage  from  stomach 
or  upper  part  of  small 
intestine ;  unless  very 
copious  (1096). 

Acute  Yellow  Atrophy 

Ankylostomiasis 

Buhl's  Disease 

Cancer  of  Liver 
*Cancer  of  Stomach,  Duode- 
num or  Intestine 

Cirrhosis  of  Liver 

Dysentery 

Embolism    of    Mesenteric 
Artery 

Enteric  Fever 

Haemophilia 

Leukaemia 

Melaena  neonatorum 

Mitral  Disease 

Parasites,  Intestinal 

Pancreatitis,  Chronic 

Portal  Obstruction 

Purpura 
*Ulcer,    Duodenal,    (Esopha  - 
geal,    Gastric,    or    Intes- 
tinal 

Melaena  is  simulated  by  the 
effect  of  the  meat  and 
hot-water  treatment.  Red 
wine,  black  cherries,  and 
blackberries  all  darken 
the  stool. 


1096.  Bright  Blood  In  Stools 

Haemorrhage  from  large, 
or  lower  part  of  small, 
intestine;  or,  when  peri- 
stalsis is  very  active, 
from  the  upper  part.  If 
mixed  with  a  fluid  motion 
it  probably  comes  from 
the  caecum  or  ascending 
colon. 

Acute  Yellow  Atrophy 

Amenorrhcea    (x) 

Amyloid  Intestine 

Anaemia,  Aplastic 

Ankylostomiasis 

Aneurysm  (rupture) 

the  haemorrhage  may,  how- 
ever, be  due  to  pressure 
upon  the  intestinal  veins 

Arsenic-poisoning 
Bilharzia,  Rectal 
*Cancer  of  Rectum  or  Intes- 
tine 
Colitis,  Ulcerative 
Dengue 

Diarrhoea,  Inflammatory 
Dysentery 

often  with  fleshy  lumps — 
'  meat  washings  ' 

Embolism,  Mesenteric 

Enteric  Fever 

not  necessarily  from  per- 
foration 

Fistula 
Gastrostaxis 

Haemoglobinuria,  Infantile- 
Haemophilia 

*Haemorrhoids,  Internal 
Infantile  Scurvy 
Injuries 

Intermittent  Fever,   Severe 
Intussusception 
Irritant-poisoning 

1094-1096 


STOOLS 


315 


Bright  Blood   in   Stools — 
continued 

Leukaemia 

Malta  Fever  (x) 

Menstruation 

Nephritis,    Chronic 

Papilloma 

Perforation  of  Bowel 

Pernicious  Remittent 

Phosphorus  -poisoning 

Polypus 
*  Portal  Obstruction 

Proctitis,  Haamorrhagic 

Prolapsus  Ani 

Purpura 

„         Henoch's 

Relapsing  Fever 

Scurvy 

*Ulcer  of  Bowel 

solitary,  tuberculous,  en- 
teric, or  syphilitic 

Ulcer,  Gastric 
Varix,  Rectal 
Vascular  Growths 
*Villous  Tumour 
Yellow  Fever 

In  suspicious  cases,  the 
guaiacol  test  must  be 
used ;  but  there  are  so 
many  sources  of  blood  in 
the  motions  that  too 
much  importance  should 
not  be  attached  to  the 
presence  of  a  small 
quantity. 

Haematoxylin,  taken  in- 
ternally, produces  red 
stools. 


1097.  Membranes   and   Shreds 
in  Stools 

Cancer  of  Intestine 
sloughs  or  portions  of  bowel 
*Colitis,   Membranous 
casts 

Croupous  Cholecystitis 

Dysentery 

Malignant  Relapsing  Fever 

Proctitis,  Acute 


1098.  Indol  Excessive 
Achylia  Gastrica 
Chlorosis 
Constipation 
Hyperchlorhydria 
Pernicious  Anaemia 

1099.  Mucus  in  Stools 

The  higher  in  the  intestine 
the  lesion,  the  less  the 
mucus  in  the  stool. 
Mucus  is  often  opaque 
and  is  sometimes  tape- 
like. That  from  the  sig- 
moid flexure  may  be 
gelatinous. 

Ascarides 

Bilharzia  of  Sigmoid  Flex- 
ure 
Cancer  of  Rectum 
*  Colitis,   Mucous 

faeces  coated  with  mucus 

Colitis,  Ulcerative 
Diarrhoea,  Inflammatory 
*Duodenal  Catarrh 

mucus  mixed  with  bile 

Dysentery 
*Enteritis 

faeces  mixed  with  mucus 
1096-1099 


316 


STOOLS 


Mucus  in   Stools — continued 

Foreign  Body 

Gastritis,  Chronic 

Haemorrhoids 

Impacted  Faeces 

Intussusception 

Polypus,  Rectal 

Proctitis 

Prolapsus  Ani 

Ulcer  of  Large  Bowel 

dysenteric,  syphilitic,  ster- 
coral, or  tuberculous 

1100.  Fat  in  Stools 

Normal  in  small  amount. 
If  the  excess  is  due  to 
pancreatic  disease,  it  will 
disappear  on  giving  a 
preparation  of  pancreas ; 
but  it  may  arise  from 
hurried  passage  as  in 
diarrhoea  or  to  eating  too 
much  fat. 

Bile-duct,  Occluded 
Coeliac  Disease 
Duodenum,  Cancer  of 
Dyspepsia  in  Infants 

undigested     fatty     portion 


of   milk, 
curds. 


These   are  not 


Enteric  Fever 

Gout 

Jaundice,  Obstructive 

Pancreas,  Calculus  in 

,,  Cancer  of 

Pancreatitis 
Pernicious  Anaemia 
Sprue 
Tuberculous  Enteritis 

*+*  '  Butter  Stools '  sometimes 
appear  in  pancreatic  in- 
sufficience. 


1101.  Undigested  Food 

Achylia  Gastrica 
*  Atony  of  Stomach 

Carcinoma 

Defective  Mastication 

Dentition 

Diarrhoea  lienterica 
*Excess     of     (or     Improper) 
Food  in  Infants 

Gastro-Intestinal  Fistula 

Elastic   fibres   are   digested 
in  the  small  intestine. 


1102.  Concretions,  etc. 

Bezoar  (Hysteria) 

Drugs 

soda,  chalk,  magnesia,  bis- 
muth, salol,  etc. 

Gallstones 
if  multiple,  they  are  faceted 

Pancreatic  Calculi 

Scybala,  Stonelike 
***  There  is  also  a  fatty  acid 
stone  produced  by  large 
doses  of  olive  oil. 


1103.  Sand  in  Stools 

It  consists  of  calcium  phos- 
phate with  a  little  oxalate. 
A  feast  of  bananas  or. 
pears  will  produce  it  in 
appearance.  The  micro- 
scope will  distinguish. 

Colic  (X) 
Colitis,  Mucous 
Colon,  Cancer  of 


1099-1103 


STOOLS 


317 


1104.  PARASITES,  OVA,  ETC. 

1105.  Nematode    Worms 

Ankylostoma  Duodenale 

about  £  inch  long  with  four 
claw -like  teeth 

Ascaris  Lumbricoides 

like  a  pale  earth-worm 

Ascaris  Mystax    (x) 

similar :  contracted  from 
cats 

Oxyuris  vermicularis 
like  small  white  threads 

Strongylus  Gibsonii 

Trichocephalus  Dispar 

2  to  3  inches  long,  tapering. 
It  is  unimportant 

Trichina  Spiralis 
1*5  to  3  mm. 

1106.  Cestode  Worms 

Bothriocephalus  Latus 

rare  in  Britain.  From  fresh- 
water fish 

Taenia  Solium 

from  pork 

2  to  4  yards  in  length ; 
head  size  of  pin's  head 
with  four  suckers  and  a 
ring  of  hooklets. 

Taenia  Mediocanellata 

from  beef 

5  to  9  yards  long,  head  with 

four     suckers      but     no 

hooklets. 

1107.  Trematoda 

Distoma    hepaticum 

25  mm.  by  12mm.,  leaf 
shaped 

Distoma  lanceolatum 
smaller  and  narrower 


1108.  Microscopic  Examina- 
tion 

About  5  grains  of  the  faeces 
should  be  shaken  up  in  a 
corked  test  tube,  rilled 
to  two-thirds  with  saline 
solution.  After  standing 
for  20  minutes,  the  super- 
natant fluid  is  poured  off. 
This  process  may  have  to 
be  repeated  several  times. 
When  clear  fluid  is  ob- 
tained it  must  be  centri- 
fuged. 

Amoeba  dysenterise 
amoebic  dysentery 

Bacillus  anthracis 
anthrax 

Bacillus  coli  communis 

normal ;  but  more  abun- 
dant in  suppuration 

Bacillus  dysenterise 
bacillary    dysentery 

Bacillus  tuberculosis 

tubercle  of  intestinal  tract 

Comma  bacillus 
cholera 

Charcot -Ley  den  Crystals 
helminthiasis 

Eggshells   or   Eggs   of   Bil- 
harzia 

Infusoria 

Ova  of  Worms  and  Anky- 
lostoma 

Streptococci 

Teischmann's  Crystals 
(blood) 

Undigested  Food 

***  The  presence  of  Bacillus 
typhosus  in  the  stool  can 
rarely  be  determined,  ex- 
cept by  culture. 

1104-1108 


318  VOMITING,  ETC. 


1109.  VOMITING,  ETC. 

The  act  of  vomiting  is  preceded  by  an  inspiration.  Then, 
with  glottis  and  pylorus  closed,  the  stomach,  diaphragm,  and 
abdominal  walls  contract  and  the  contents  of  the  stomach  are 
expelled.     The  vomiting  centre  is  near  the  calamus  scriptorius. 

The  following  tests  for  cancer  of  the  stomach  have  been  found 
unreliable  : — The  Fatty  Acid  in  Urine  Test,  Gluzinski's  Trypto- 
phen  Reaction,  and  Saloman's  Test.  The  last,  which  depends 
upon  the  detection  of  albumen  in  the  vomit,  has  been  some- 
what rehabilitated,   however. 

1110.  Free  Hydrochloric  Acid. — Take  about  half  a  drachm 
of  the  vomit,  and  add  an  equal  quantity  of  Giinsberg's  reagent 
on  a  porcelain  dish.  A  red  band  will  appear  on  evaporation. 
The  reagent  consists  of — phloroglucin,  2  grammes ;  vanillin,  1 
gramme  ;  and  absolute  alcohol,  30  grammes.  It  is  somewhat  un- 
stable, and  I  find  it  more  convenient  to  soak  white  paper  in  it.  The 
dried  test  paper  thus  prepared,  when  heated  over  a  flame,  gives 
the  red  coloration  in  the  presence  of  free  hydrochloric  acid.  The 
stomach  having  been  flushed,  the  patient  should  take  an  Ewald 
meal,  which  consists  of  a  roll  and  two  cups  of  water.  One  hour 
afterwards  the  gastric  contents  should  be  withdrawn  and  examined. 
The  reason  for  not  waiting  is  that  the  proteids  combine  with  the 
HC1  so  that  the  latter  is  then  no  longer  free. 

1111.  Lactic  Acid  (Keeling's  Test). — After  a  Boas  meal, 
add  one  or  two  drops  of  a  5  per  cent,  solution  of  perchloride 
of  iron  to  5  c.c.  of  the  vomit  diluted  with  50  c.c.  of  water.  If 
lactic  acid  is  present,  a  green  coloration,  best  seen  against  a  white 
background,  will  result.  The  Boas  meal  is  made  by  stirring  a 
tablespoonful  of  oatmeal  in  a  quart  of  water  and  boiling  down  to 
a  pint.  The  stomach  is  to  be  thoroughly  washed  out  one  hour 
before,  and  its  contents  removed  one  hour  after,  the  meal. 
(Bread  sometimes  contains  lactic  acid.) 

1112.  Uffelmann's  Reagent  for  lactic  acid  consists  of  one 
part  carbolic  acid(l  in  20)  with  two  parts  distilled  water.  Mixed 
with  the  vomit,  it  gives,  when  a  few  drops  of  FeCl2  solution  are 
added,  a  purple  colour  which  is  turned  yellow  by  lactic,  and 
brown  by  acetic  or  combined  hydrochloric,  acid. 

1109-1112 


VOMITING,  ETC. 


319 


1113.  Congo  Paper. — The  red  paper  turns  blue  with  free 
hydrochloric  acid  and  with  lactic  and  other  free  organic  acids, 
the  blue  being  not  so  intense  in  the  case  of  the  latter. 


1114.  Nausea  and  Retching 

Ague  (prsem.) 
*Alcoholism 
Appendicitis 
Anaemia  of  Brain 
Arsenic-poisoning 
Cancer  of  Colon 

„        of  Liver 

,,        of  Pancreas 
Catarrh  of  Bile-ducts 
Cholera,        Sporadic        and 

Asiatic 
Cirrhosis  of  Kidney 
Concussion  of  Spine 
Congestion  of  Liver 
Conium-poisoning 
Enteritis,  Acute 
Foreign  Body  in  Throat 
*Gastric  Irritation 
Gastritis,  Acute  and  Chronic 
Hernia 

Hooping  Cough 
Hydrophobia 
Irritant  -poisoning 
Lead  Colic 
Measles    (prodr.) 
Mediastinal  Tumour 
Meniere's  Disease 
Meningitis  Simplex 
Migraine 
Neurasthenia 
Paralysis,  Infantile 

onset 

Pelvic  Cellulitis 

„       Peritonitis 
Perforation  of  Stomach 
Peritonitis 


Pharyngitis,  Chronic 

Poisoning,  Irritant 

Post-pharyngeal  Abscess 
*Pregnancy 
*Ptomainism 

Quinsy 

Relaxed  Uvula 

Roundworms 

Scarlatina 
*Sea-sickness 

Shock 

Typhus 

Variola  (prodr.) 

Yellow  Atrophy,  Acute 

1115.  Rumination    or   *  Mery- 
cism* 

Epilepsy 
Hysteria 
Idiocy 
Neurasthenia 

1116.  Regurgitation  of  Food 

Aneurysm 

Angina,  (Esophageal 

(?)  previously  unrecorded. 

Bulbar  Paralysis 
Cancer  of  (Esophagus 
Dilatation    of     (Esophagus, 

Idiopathic 
Fibrous  Stricture 
Myasthenia  Gravis 
Pouch,  (Esophageal 
Rumination   (1115) 
Spasm  of  (Esophagus 
Tumour,  Intrathoracic 

1113-1116 


320 


VOMITING,  ETC. 


VOMITING 

Tho  classification  hero  adopted  is  [convenient,  but  it  involves 
some  overlapping.  .  Certain  forms  of  vomiting,  too,  are  of  a  mixed 
character. 


1117.    Cerebro-spinal   or   Pro- 
jectile Vomiting 
Abscess,  Cerebral 
Apoplexy 

♦Cerebellar  Disease 
Compression  of  Brain 
Concussion  of  Brain 

„  of  Cord 

Epilepsy 
Hydrocephalus 
Hyperemia  of  Brain 
Hypertrophy  of  Brain 
Hysteria 

Locomotor  Ataxy 
gastric  crisis 

Meniere's   Disease 
Meningitis,  Cerebro-spinal 
„         Simple 
„         Tuberculous 
Migraine 

Poliomyelitis,  Ant.  Acute 
onset — often  recurrent 

*Sea-sickness 
Shock 
Spinal   Paralysis,    Acute 

adult  form 
Stokes-Adams'  Disease 
Thrombosis,  Sinus 
Tumour  of  Brain 

esp.  subtentorial 


1118.  Irritative  and  Obstructive 
Vomiting 

Adhesions 
Alcoholism 
Amyloid  Liver 
Appendicitis 
Botulism 
Cancer  of  Colon 

„      of  Duodenum 
Cancer  of  Liver 

independent  of  meals 
Cancer  of  Pancreas 
Cancer  of  Pylorus 

long  after  meals 

*Cancer  of  Stomach 
Catarrh  of  Bile-ducts 
Cholera,  Asiatic 

„        Sporadic 
Cirrhosis  of  Liver 

,,         of  Stomach 
*Colic 
♦Dilatation  of  Stomach 

large  quantities  at  long 
intervals 

Emetics,  Action  of 

Enteritis,  Acute 

Gastritis,  Acute  and  Chronic 

Gastralgia 

Gastric  Irritation 

Henoch's  Purpura 
♦Hernia 

esp.  when  strangulated 

Hour-glass  Stomach 

Hypertrophy  of  Pylorus 

♦Intestinal   Obstruction 

early  if  in  small  intestine, 
later  and  faecal  if  in  large 
intestine 

1117-1118 


VOMITING,  ETC. 


321 


Irritative  and  Obstructive 

Trichinosis 

Vomiting — continued 

*Ulcer  of  Duodenum 

Intussusception 

u  2  hours  after  food 

faecal  if  near  valve 

Ulcer  of  Intestine 

♦Irritant  Food 

*Ulcer  of  Stomach 

Ileal  Kink 

soon  after  food 

Kidney,  Movable 

Volvulus 

when  adherent 

Worms 

Liver,  Cyanotic 

Pancreatitis 

1119.  Reflex  Vomiting 

Pellagra 

Asthenopia 

Peritonitis,  Acute 

Astigmatism 

Poisoning  by  : — 

Bronchial  Glands,  Enlarged 

Aconite 

Bronchiectasis 

Antifebrin 

Cystitis 

Antimony 

Dysmenorrhea 

Antipyrin 

Endocarditis,  Ulcerative 

Arsenic 

Exophthalmic  Goitre 

Cantharides 

Gestation,  Extra-uterine 

Chloroform 

Glandular  Fever 

Copper 

Hepatic  Abscess 

Digitalis 

*        „       Colic 

Ergot 

Hepatitis,  Acute 

Iodine 

Hooping  Cough 

Lead  (x) 

Hydronephrosis 

Mercury 

Hysteria 

Mushrooms 

Intercostal  Neuralgia 

Nicotine 

Locomotor  Ataxy 

Petroleum 

Lung,  Fibroid 

Phosphorus 

Lymphadenoma 

Silver 

Mediastinal  Tumour 

Sulphonal 

Metritis,  Acute 

Trional 

♦Migraine 

Veronal 

Mountain  Sickness 

Zinc 

Movable  Kidney 

Portal    Obstruction 

Myocarditis,  Acute 

Pfcomainism 

Oophoritis 

Roundworm 

Ovarian  Cyst 

Stricture  of  (Esophagus 

Pelvic  Cellulitis 

♦Stricture  of  Pylorus 

,,      Peritonitis 

Thrombosis,  Mesenteric 

Pneumonia,  Lobular 

"3 

f                            1118-1119 

322 


VOMITING,  ETC. 


Keflex  Vomiting — continued 
♦Pregnancy 

u  to  third  month 
Prostatitis 
Renal  Calculus 
Sea-sickness 
Shock 
Trichinosis 
Uterus,  Retroversion  of 

Vomiting  also  occurs  after 
blows  upon  the  epigas- 
trium or  testicle  and 
from  offensive  sights  and 
smells. 

1120.  Toxaemic  Vomiting 

Acute  Yellow  Atrophy 
Acetonuria 
Addison's  Disease 
Ague  (prsem.) 
Anaemia 

Angio -neurotic  (Edema 
Cirrhosis  of  Kidney 
Conium  -poisoning 
Cyclical  Vomiting 
Diabetes,  in. 
Endocarditis,  Septic 
Gangrene  of  Lung 
Gout,  Undeveloped 
Hsemoglobinuria,  Infantile 
Influenza 
Milroy's  Disease 

crisis 
Mumps  (onset) 
Nephritis 
Paroxysmal      Haemoglobin- 

uria 
Pernicious  Anaemia 
Remittent  Fever 
Roseola 

♦Scarlatina  (onset) 
Sewer  Gas 


Typhic  State 
Ulcerative  Endocarditis 
Uraemia 

vomit  said  to  contain  urea 

Variola  (onset) 
Weil's  Disease 
Yellow  Fever 

I.   clear ;    n.   black 


1121.  Hsematemesis  (Vomiting 

of  Blood) 

The  blood  is  usually  dark, 
clotted,  free  from  froth 
and  mixed  with  food. 
It  often  resembles  coffee- 
grounds. 

Acute  Yellow  Atrophy 
♦Amenorrhcea 
Aneurysm,  Rupture  of 
Appendicitis  (x) 

,,  Larvata 

Buhl's  Disease 
Cancer  of  Liver 

„     of  (Esophagus 
Cancer  of  Stomach 
20  per  cent. 

Chloroma 
Cholera  (x) 
Cirrhosis  of  Kidney 

,,  of  Liver 

„  of  Stomach 

Cyanotic  Liver 
Dengue 

Dilatation  of  Stomach  (x) 
Diphtheria  (x) 
Foreign  Body 

perforating 
Gallstone 

ulcerating  into  duodenum 

1119-1121 


VOMITING,  ETC. 


323 


H;ematemesis — continued 
Gastritis,  Chronic 
Gastrostaxis 

(oozing  of  blood) 
Glass,  Swallowed 

e.g.  from  broken  tube  of  a 
feeding-bottle 

Haemophilia 
Infantile  Scurvy 
Intussusception  (x) 
Leukaemia 
Lymphadenoma,  in. 
Malarial  Cachexia 
Malingering 
Mediastinal  Growth 

ulcerating 
Mitral  Stenosis 
Pancreatico  -  Duodenal 

Fistula 
Pancreatitis,  Acute 
Pernicious  Anaemia 
Poisoning  by  : — 

Arsenic 

Antimony 

Corrosives 

Phosphorus 
Portal  Obstruction 
*Portal  Thrombosis 
Purpura 
Pyaemia 

Pylephlebitis,  Adhesive 
Remittent,  Severe 
Rupture  of  Varicose   (Eso- 
phageal Vein 
Scarlatina,  Malignant 
Scurvy  (x) 
♦Splenic  Anaemia 
Syphilis  of  Stomach 
Trauma 
Typhus 
Ulcer  of  Duodenum 


*  * 
* 


*Ulcer  of  Stomach 
50  per  cent. 

Uraemia 
*Valvular  Disease 

Variola,  Malignant 

Weil's  Disease 

Yellow  Fever 

Exclude  swallowed  blood 
coming  from  lungs,  nose, 
and  teeth,  and,  in  infants, 
from  the  mother's  cracked 
nipples. 

1122.  Eructations     and     Acid 
Risings 

Aerophagia  Nervosa 

Angina  Pectoris  (term.) 

Atony  of  Stomach 
*Dilatation  of  Stomach 

Dysentery 

Gastralgia 

Gastric  Irritation 
„       Ulcer 

Gastro-Succorrhcea 
*Hyperchlorhydria 

Hysteria 

Metritis,  Acute 

Neurasthenia 

(Esophageal  Pouch 

can  be  emptied  by  pressure 
above  left  clavicle 

Peritonitis 
Trichinosis 


1123.  Pyrosis  or  Waterbrash 

Clear-water    vomit,     some- 
times very  copious. 

Cancer  of  Pancreas 
Dyspepsia 
*Gastritis,  Chronic 

2  1121-1123 


324 


VOMITING,  ETC. 


1124.  Gastric  Motility  and  Pan- 
creatic Test 

To  test  this,  half  a  gramme 
of  salol  in  glutoid  cap- 
sules is  swallowed  with 
an  Ewald  meal.  The 
urine  should  give  a  violet 
coloration  with  per- 
chloride  of  iron  within 
4  to  6  hours.  Pancreatic 
juice  digests  the  glutoid 
capsule,  and  a  delay  may 
mean  : — 

Cancer  of  Head  of  Pancreas 

,,       of  Stomach 
Dilatation  of  Stomach 
Obstruction  of  Duct  Orifice 
Stricture  of  Pylorus 

CHARACTER 

1126.  Hyperchlorhydria 

Excess  of  free  hydrochloric 

acid  (1110) 
Less  diagnostic  importance 
is  attached  to  this  con- 
dition now. 
Gastralgia 
Gastric  Irritation 
*Gastric  Ulcer 

1127.  Hypoehlorhydria 

Absence  or   diminution    of 
free  hydrochloric  acid. 

Achylia  Gastrica 

Anaemia 

Atrophy  of  Gastric  Mucous 

Membrane 
*Cancer  of  Stomach 
progressive  diminution 
Carcinoma;  Systemic 
Dilatation  of  Stomach 
Gastritis,  Acute 

„  Alcoholic 

Hysteria 
Kidney,  Tumour  of 


1125.  Currant  Test 

A  delay  of  over  24  hours  in 
finding  the  fruit  or  seeds 
after  a  currant  meal 
implies  impaired  gastric 
motility. 

Cancer  of  Stomach 
Dilatation  of  Stomach 
Pyloric  Stricture 


OF  VOMIT 

Myxcedema 
Nephritis 
Neurasthenia 
Pernicious  Anaemia 
Pulmonary  Tuberculosis 

***  Free  HC1,  however,  is  said 
to  be  normally  absent  in 
40  per  cent,  of  persons 
over  50  years  of  age. 

1128.  Lactic  Acid   after  Boas 

Meal 

Lactic  and  Acetic  Acids 
indicate  fermentation  pro- 
cesses in  the  stomach. 

Atrophy  of  Stomach 
Cancer  of  Stomach 
*Dilatation  of  Stomach 
Hour-glass  Stomach 
(See  1111) 

Blood  (see  Hcematemesis,  1121) 

Coffee-ground     (see     Hczmate- 
mesis, 1121) 

1124-1128 


VOMITING,  ETC. 


325 


1129.  Albumose 
In  Excess 

Gastric  Ulcer 
Deficient 

Cancer,  Gastric 
Gastric  Atrophy 
Gastritis,  Acute 

1130.  Succus  Entericus 

This  can  be  detected  by  its 
power  of  digesting  white 
of  egg  in  an  alkaline 
medium. 

Intestinal  Obstruction 
Pyloric  Incompetence 
Vomiting,  Prolonged 

1131.  Bile 

Vomiting  with  stomach 
empty.  Normal  bile  has 
not  a  bitter  taste. 

Duodenal  Obstruction 

below  duct 
Hepatic  Colic 

termination 

1132.  Mucus 

Chronic  Gastritis 

Dilatation  of  Stomach 

***  Swallowed    sputa   must    be 
excluded. 


1133.  Pus 

Abscess,  Rupture  of 

Gastritis,  Phlegmonous 

Exclude  swallowed  pus,  e.g. 
from  quinsy. 

1134.  Sarcinae  and  Torulae 

Cancer  of  Pylorus 
Dilatation  of  Stomach 

1135.  Bacillus  Filiformis 

Cancer  of  Stomach 

if    abundant    in    a    nearly 
empty  stomach  (Boas) 

1136.  Oppler  Boas  Bacillus 

Cancer  of  Stomach 
Dilatation  of  Stomach 
Lactic  Acid  with  Stagnation 

1137.  Fsecal  Vomiting 

Colon,  Obstructed 
Gastro-colic  Fistula 
Hernia,  Strangulated 
Peritonitis,  Severe 
Volvulus 

1138.  Jaworski's  Kernels 

The  free  nuclei  of  epithelium 
cells  or  of  leucocytes. 

Hyperchlorhydria 


1129-1138 


326 


SPUTA 


1139.  THE  SPUTA 

The  naked-eye  appearances  of  the  expectoration  are  indi- 
cated by  the  groups  into  which  this  section  is  divided.  By  far 
the  most  important  microscopical  examination  is  the  search 
for  the  Tubercle  Bacillus.  The  expectoration  selected  should  be 
that  of  the  morning,  and  if  possible  should  include  one  of  the 
small  cheesy  masses.  For  technique,  see  1553.  It  must  be 
remembered  that  tubercle  bacilli  rarely  appear  in  the  sputa 
till  the  stage  of  softening  has  been  reached. 

1140.  Elastic  Tissue. — The  presence  of  elastic  tissue  is 
generally  indicated  when  flocculi  are  observed.  To  see  the 
hooked  and  curled  fibres  under  the  microscope,  the  sputa  should 
be  boiled  with  an  equal  quantity  of  a  10  per  cent,  solution  of 
caustic  soda.  The  gelatinous  mass  must  be  well  diluted  with 
water  and  the  sediment  centrifuged. 

The  sputa  in  uraemia  often  contains  urea.  Of  the  following 
divisions,  two  or  more  may  co-exist  in  the  same  patient.  This 
is  specially  true  of  sputa  cruda  and  sputa  cocta,  where  it  is  prob- 
ably merely  a  question  of  longer  or  shorter  retention. 


1141.  Scanty  Sputa 
Asthma,  Spasmodic,  I. 
Bronchitis,  Acute 

onset 
Cancer  of  Lung 
Catarrhe  sec 

Diphtheritic  Laryngitis,  I. 
Hay  Fever 
Laryngitis,  Chronic 
Pleurisy,  Acute 

or  absent 
Pneumonia,  Acute 

onset 
Tuberculosis,  Acute  Miliary 

1142.  Frothy  Sputa 

Denser  after  a  night's  rest 
because  the  bubbles  have 
had  time  to  burst. 

♦Bronchitis,  Acute 


Bronchorrhcea 

watery  and  abundant 
Emphysema 
Gangrene  of  Lung 

upper  layer  of  sputa 
(Edema  of  Lungs 

'  wine-froth '     or,     if     free 
from  blood,  '  soapsud  ' 

Pneumonia,  Acute  Lobular 

1143.  Viscid  or  Sticky  Sputa 

Broncho  -pneumonia 
Hooping  Cough 
Phthisis 

pneumonic  form 
*Paeumonia,  Acute 

Millers  and  bakers  get  a 
viscid  lining  to  the  air 
tubes  from  inhaling  flour. 

1139-1143 


* 


SPUTA 


327 


1144.  Mucous    or   Translucent 
(Sputa  cruda) 

Asthma,  Spasmodic 

termination  of  a  slight 
attack 

Bronchial  Glands,  Enlarged 
Bronchitis,  Acute 

termination 
Broncho-pneumonia 
Catarrhe  sec 

'  pituitary  sputa  ' 
Emphysema 
Enteric  Fever 
Hooping  Cough 
Infiltrated  Cancer  of  Lungs 
Influenza 
Laryngitis,  Acute 
Measles 

Mediastinal  Abscess 
Pharyngitis 
Phthisis,  i. 

1145.  Muco-purulent  or  Opaque 
(Sputa  cocta) 

Asthma,  Spasmodic 
end  of  severe  attack 

*Bronchitis,  Chronic 
Hooping  Cough,  ni. 
Hydatids  of  Lung 
Measles  (defervescence) 
Phthisis,  in. 
Pneumonia,  Acute 
stage  of  '  resolution  ' 

1146.  Nummular  Sputa 

Concrete  circular  masses. 
The  shape  is  usually  that 
of  the  pouch  or  cavity  in 
which  the  sputum  collects. 

Bronchorrhcea 


Bronchiectasis 

Cirrhosis  of  Lung 

*Phthisical  Cavity 

Pneumonia  (x) 

Sinking  in  water  implies 
long  retention. 

1147.  Purulent  Sputa 
Bronchial  Glands,  Enlarged 
Bronchitis,  Acute,  m. 

*Bronchitis,  Old  Chronic 
Broncho -pneumonia 
Bursting  of    an   abscess    or 

collection   of    pus   into   a 

bronchial  tube  : — 

diaphragmatic,  pulmonary, 
hepatic,  or  mediastinal 
abscess ;  empyema  or 
pyonephrosis. 

1148.  Blood-streaked 

Usually  due  to  the  violence 
of  the  cough. 

Abscess  of  Lung 

Adenoids 

Aneurysm 

Aspergillosis 

Bronchitis,  Acute  (x) 

„  Chronic  (x) 

♦Bronchitis,  Plastic 
*Cancer  of  Lung 

Emphysema 

Haemoptysis 

passing  off  or  prsemon. 

Laryngeal  Growth 

Laryngitis 

Malformation  of  Heart 

Mediastinal  Abscess 
*Pharyngitis,  Chronic 
♦Pharyngitis,  Granular 

Phthisis,  n. 

Pneumonia,  Acute 

1144-1148 


328 


SPUTA 


Blood-streaked — continued 
Pulmonary  Apoplexy 

dark 
Tonsillitis 
Typhus  (prodr.) 
Ulcer  of  Larynx 
*Varix,  Pharyngeal 

Also  from  bleeding  teeth, 
spongy  gums,  or  from 
retching. 

1149.  Haemoptysis 

Vomiting  of  bright -red  and 
often  frothy  blood  un- 
mixed with  food. 

Actinomycosis 
Amenorrhcea 
vicarious 
*  Aneurysm,  Bursting  of 
systemic  or  pulmonary 

Angioma  Laryngis 
Aortic  Cusp  Rupture 

„       Regurgitation 
Arterio-sclerosis 
Aspergillosis 
Blows  on  Chest 
Bronchiectasis 
Bronchial  Glands,  Enlarged 
Bronchitis  (x) 

„  Plastic 

Bronchorrhcea 
Cancer  of  Larynx 

„      of  Lung 
Cirrhosis  of  Lungs 
Congestion  of  Lungs 

mechanical 
Diaphragmatic  Abscess 

bursting  into  lung 
Distoma  pulmonale 

chronic   recurrent   haemor- 
rhage 


Emphysema  (x) 
Empyema 

on  bursting 
Endarteritis,  Pulmonary 

in  gouty  persons 

Eat  Embolism 
Foreign  Body,  Impacted 
Fractured  Ribs 
piercing  lung 

Gangrene  of  Lung 
Haemophilia 
Hepatic  Abscess 

bursting  into  lung 
Hydatids  of  Lung 
Hypertrophy  of  Heart 
Jaundice  (x) 

Laryngitis,  Hemorrhagic 
Larynx,  Cancer  of 
„        Lupus  of 
,,         Ulceration  of 
Leukaemia 

Lung-Fluke  of  Corea 
Lymphadenoma 
Malformation  of  Heart 
Malignant  Fevers 
Malingering 

gum  sucking 

Mediastinal  Tumours 
Mitral  Stenosis  and  Regur- 
gitation 
Pernicious  Anaemia 
*Phthisis 

60  per  cent. 

Plague 
Pleurisy,  Old 
rupture  of  adhesions"] 

Pneumonia,  Acute  (x) 

,,  Septic 

Pneumonoconiosis 

1148-1149 


SPUTA 


329 


Hemoptysis — continued 
Pulmonary  Embolism 

„  Thrombosis 

Purpura 

Sarcoma  of  Lung 
Scurvy 

Syphilitic  Disease  of  Lungs 
Traumatism 
Typhus (x) 
Variola,  Hemorrhagic 
Varix  of  Lingual  Tonsil 

*+*  Beware     of     malingerers, 
epistaxis  posterior,  etc. 

Bacterium      Prodigiosium 
growing  in  the  air  passages 
produces  red  sputa. 

1150.  Rusty  Sputa 

Distomiasis 
*Pneumonia,  Acute 
Pyaemia 
Siderosis 

magnetic  oxide  of  iron 
Tuberculosis,  Acute  (x) 

1151.  *  Currant  Jelly  '  Sputa 
Cancer  of  Lung 
Hysteria  (?) 

1152.  ■  Prune-juice  ■  Sputa 

C*Cancer  of  Lung 
Gangrene  of  Lung 
(Edema  of  Lung 
pneumonia,  Septic 
Sarcoma  of  Lung 

1153.  Anehovy  Sauce  Sputa 
Hepatic  Abscess,  Amoebic 

bursting  into  lung 


1154.  '  Boiled  Sago  '  Sputa 

A  nearly  globular  mass 
resembling  a  grain  of  the 
above — often  black.  It  is 
formed  in  the  laryngeal 
pouch. 

Laryngeal  Catarrh 
Laryngitis,  Chronic 


1155.  Casts 

*Diphtheria 

Membranous  Laryngitis 

*Plastic  Bronchitis 

tree-like  when  suspended  in 
water — soluble  in  caustic 
alkalies. 

Pneumonia,  Acute  (x) 


1156.  Black  Specks 

Anthracosis 
Gangrene  of  Lung 
Inhalation  of  Coal-dust,  Fog, 

or  Smoke 
Phthisis  (x) 

1157.  *  Gooseberry-skins  • 
(Eehinococei) 

Hydatids  invading  a  lung. 

1158.  Calcareous  Concretions 

These  form  with  great  rarity 
in  the  lungs  and  may 
appear  in  the  sputa. 

1159.  Dittrieh's  Plugs 

They  look  like  mustard 
seeds. 

Bronchiectasis 

***  Plugs   from   the   tonsillary 
crypts  must  be  excluded. 

1149-1159 


330 


SPUTA 


1160.  Blue  Sputa 
Bacillus  Pyocyaneus 


*.  * 


Also  workers  in  ultramarine. 


1161.  Greenish  or  Bilious  Sputa 
Actinomycosis 
Carcinoma  (x) 
Chloroma 

Gallstones,  Impacted 

with  biliary  fistula 
Hepatic  Abscess 

with  fistula 
Icteric  Pneumonia 

1162.  Fetid  Sputa 

Abscess,  Subphrenic 
Actinomycosis 
Bronchiectasis 
Cirrhosis  of  Lung 
Empyema,  Bursting 
*Gangrene  of  Lung 

with  tinder-like  masses 
Phthisis 

large  cavity 
Syphilitic  Laryngitis 


1163.  Albuminous  Sputa 

The  mucus  must  be  pre- 
cipitated from  the  sputa 
(previously  mixed  with 
saline  solution)  by  acetic 
acid  and  the  filtrant 
boiled. 

Albuminuria 
Broncho-pneumonia 
Miliary  Tuberculosis,  Acute 

(x) 
Mitral  Disease 
(Edema  of  Lung 
Pleurisy,  Serous 

bursting  into  lung 

Pneumonia,  Acute 
Tuberculosis,  Pulmonary 

the  quantity  is  in  proportion 
to  the  activity  of  the 
disease. 
***  When  found  after  para- 
centesis, it  is  due  to 
oedema  of  the  lung. 


1160-1163 


SPUTA 


331 


1164.  MICROSCOPIC  CHARACTERS 


1165.  Curschmann  Spirals 

Visible  under  a  low  magni- 
fying power  as  corkscrew- 
like fibres  of  mucus 
showing  a  central  thread. 

Asthma 

Bronchitis,  Capillary 

„  Plastic 

(Edema  of  Lung 

Phthisis 

Pneumonia  (x) 

***  Not    present    in    renal    or 
cardiac  asthma. 

1166.  Chareot-Leyden  Crystals 

Long  pointed  vitreous  octa- 
hedra. 

Asthma,  Spasmodic 
Bronchitis,  Chronic 
,,  Plastic 

Emphysema 

1167.  Fat    or  C  holes  tear  in 
Crystals 

Dermoid  Cyst 
Gangrene 
Phthisical  Cavity 
Pulmonary  Abscess 

1168.  Blood  Crystals 
Old  Haemorrhage 

1169.  Elastic  Tissue 

Curling  fibres   (1169). 

Bronchiectasis 
Phthisis,  n. 
Pneumonia,  Acute  (x) 
Pulmonary  Abscess 


1170.  New  Growth  Particles 

These  may  sometimes  be 
detected  by  centrifuging 
diluted  sputa. 

Cancer 
Myelosarcoma 

1171.  Pollen 

Often  adventitious. 
Hay  Asthma 

1172.  Hooklets 

Hydatids  of  Kidney  or  of 
Liver  bursting  into  Lung 
Hydatids  of  Lung 

1173.  Eosinophile  Cells 

*  Asthma 

numerous 
Bronchitis,  Chronic 

a  few 
Bronchitis,  Plastic 

1174.  Brown   Pigmented   Epi- 
thelial Cells 

Answers  to  the  blood  test 
(962). 

Brown  Induration  of  Lung 

Mitral  Stenosis 

1175.  Distoma  Pulmonale,  or 
its  Ova 

Distomiasis 

1176.  Paragonimus      Wester- 
mani 

(Liver  Fluke  of  Corea) 
Haemoptysis 

1164-1176 


332 


SPUTA 


1177.  Actinomyces 

Radiating  clubs  10  to 
60  fx  x  10  fi 

Actinomycosis 

1178.  Aspergillus  Fumigatus 

A  small-spored  fungus 

Aspergillosis  Pulmonum 

1179.  Staphylococcus  Pyogenes 

Abscess 

1180.  Pneumococci 
Capillary  Bronchitis 
Empyema 

*Pneumonia,  Acute 

A  few  are  normally  present 
in  the  saliva. 

1181.  Friedlander's  Bacillus 

Pneumonia,  Acute 

in  5  per  cent,  of  the  cases 

1182.  Pfeiffer's  Bacillus 

Slender,  with  rounded  ends. 
Influenza 

1183.  Klebs-Loeffler     Bacillus 

Diphtheria 

1184.  Bacillus  Mallei 

Glanders 


1185.  Bacillus  Pertussis 

(Of  Bordet  and  Gengou) 
Hooping  Cough 

1186.  Bacillus   Tuberculosis 
(1553) 

Phthisis 

Tuberculosis,  Acute  Miliary 

1187.  Bacillus  Typhosus 

Enteric  Fever  (x) 

1188.  Amoeba  coli 

Hepatic    Abscess,    bursting 
into  Lung 

1189.  Spirochetse 

Gangrenous  Stomatitis 

1190.  Oidium      Albicans      or 
Leptothrix 

Pharyngomycosis 
'  Phthisis  '  of  Ceylon 
Thrush 

1191.  Hairs  or  Teeth 

The  former  usually  adven- 
titious. 


Dermoid 
stinum 


Cyst    of    Media- 


1177-1191 


COUGH 


333 


1192.  COUGH 

In  the  act  of  coughing,  a  deep  inspiration  is  followed  by 
closure  of  the  glottis,  which  is  then  suddenly  forced  open  by 
a  strong  expiration.  When  the  tubes  are  filled  with  secretion, 
or  are  otherwise  encroached  upon,  it  may  be  impossible  to  take 
in  sufficient  air  to  produce  an  effective  cough.  But  many 
patients  seem  to  think  that  they  can  cough  without  the  pre- 
liminary inspiration  ;  the  consequence  is  that  they  wear  them- 
selves out  with  short  and  useless  coughs.  If  the  cough  is  due 
to  the  presence  of  sputa  or  a  foreign  body,  it  is  beneficial ;  but 
if  due  to  irritation  consequent  upon  ulceration  or  dryness,  it 
is  harmful  and  should  be  suppressed. 

A  cough  may  be  excited  by  irritation  of  any  branch  of  the 
pneumogastric,  even  the  auricular  branch  ;  a  familiar  instance 
is  the  cough  sometimes  produced  by  inserting  the  ear-piece 
of  a  stethoscope  into  the  meatus. 


1193.  Dry  or  Hacking 

All  coughs  are  dry  to  begin 
with  and  reflex  coughs 
continue  so. 

Acid  Fumes 
*Acute  Bronchitis,  I. 
Adenoids 
Aspergillosis 
Bronchial  Catarrh,  i. 
Catarrhe  sec 
Enteritis,  Chronic 
Foreign  Body 

in  air  passages  or  ear 

Gastritis,  Chronic 
Hay  Asthma 
Hepatitis,  Acute 
Hepatoptosis 

ceases  on  lying  down 
Hypertrophy  of  Heart 
Hysteria 
Influenza,  I. 
Laryngeal    Paralysis 

or  toneless 


Laryngitis,  Chronic 

Naso -pharyngeal  Catarrh 

Nervousness 
*Pieurisy,  Acute 

Phthisis,  Early 

Pneumonia,  Acute,  i. 

Polypus  in  Nose  or  Ear 
♦Relaxed  Uvula 

Rhinitis 

Septum,   Spur  of 
Wax  in  Meatus 


1194.  Hoarse  or  Barking 

The    '  bark '    implies    that 
the  larynx  is  involved. 

Aneurysm  of  Aorta 
brassy 

'  Barking  Cough  of  Puberty  ' 
Bronchitis,  Acute,  i.  (x) 
Diphtheritic    Laryngitis,    i. 
but  later,  aphonic 

1192-1194 


334 


COUGH 


Hoarse    or    Barking  —  con- 
tinued 
Hooping  Cough,  I. 
Hydrophobia 
Hysteria 

Irritation  of  Stomach 
♦Laryngitis,  Acute 

,,  Membranous 

,,  Spasmodic 

♦Laryngitis,  Syphilitic 

„  Tuberculous 

Masturbation 
♦Measles 

Mediastinal  Tumour 
(Edema  Laryngis,  I. 
Perichondritis  Laryngea 
Pharyngitis,  Granular 
Pneumothorax 
metallic 

Polypus  of  Larynx 
Typhus 

1195.  Paroxysmal  Cough 

A  common  cause  of  paroxys- 
mal cough  is  the  passage 
into  the  larynx  of  mucus 
from  the  posterior  nares, 
or  of  saliva. 

♦Bronchial  Glands,  Enlarged 

Bronchiectasis 

Bronchitis,  Plastic 

Bronchorrhcea 

Calculus,  Bronchial 

Caries  of  Dorsal  Spine,  I. 

Cirrhosis  of  Lung 
♦Foreign  Body  in  Air- passage 

Gallstones  (x) 

♦Hooping  Cough 

a  succession  of  quick  short 
coughs,  ending,  when  the 
child  is  out  of  breath, 
with  a  '  whoop  ' 


Hysteria 
Influenza 
Laryngeal  Vertigo 
Laryngitis,  Chronic 
Mediastinal  Tumour 
Mediastinitis 
♦Phthisical  Cavity 
Polypus  of  Larynx 
Tonsils,  Hypertrophied 
Ulcer  of  Epiglottis 
Uvula,  Relaxed 

1196.  Unclassified  Coughs 

Broncho -pneumonia 
Cancer  of  Lungs 
Collapse  of  Lungs 
continual  and  powerless 

Congestion  of  Lungs 
Diphtheritic  Paralysis 

on  eating 
Emphysema 
Empyema 

chiefly  on  movement 
Enteric  Fever 
Hydatids  of  Liver  (x) 

„         of  Lungs 
Hyperemia  of  Lungs 
Lesion  of  Medulla 
Leukaemia 

Lingual  Tonsil,  Enlarged 
Malformation  of  Heart 
Measles 
Mediastinal  Tumour 

'  brassy  ' 
GEdema  of  Lungs 

with  retching 
Perihepatitis 

on  palpation  of  liver 

Pharyngitis,  Acute 
Phthisis 

1194-1196 


COUGH 


335 


Unclassified     Coughs — con- 
Untied 
Post-pharyngeal  Abscess 
Pregnancy 

Pressure  on  Diaphragm 
by  tumours,  enlarged  liver, 
etc. 

Pressure  on  Pneumogastric, 
Recurrent,  or  Sympathe- 
tic Nerve 
Tuberculosis,   Acute 
Tuberculous  Laryngitis 
on  eating 

Typhus 
Woillez'  Disease 


1197.  Inability  to  Cough 
Ascites,  Advanced 
Coma 

Diaphragmatic  Pleurisy 
Fractured  Ribs 
Narcotic  -poisonin  g 
Paralysis    of  Adductors 
,,  of      Respiratory 

Muscles 
Prostration 


1196-1197 


336 


BREATH 


1198.  ODOURS  OF  BREATH 

In  cases  where  the  offensive  odour  comes  from  the  mouth  the 
smell  is  absent  in  the  air  expired  from  the  nostrils  when  the  mouth 
is  closed  and  vice  versa.  If  the  smell  comes  equally  from  mouth  and 
nose,  the  source  is  in  the  pharynx  or  air  passages. 


1199.  Sweet  Breath 

Acetonuria 
ethereal 
♦Diabetes 

'  new-mown  hay ' 

Lactation 
Menstruation  (x) 
Pyaemia 
Septicaemia 
***  The  sweetish  breath  of  beer 


drinkers  is  due 

acetate. 


to   amyl 


1200.  Bitter-Almond  Breath 

Hydrocyanic-acid-poisoning 

Exclude     flavoured     cakes, 
etc. 

1201.  Alliaceous  Breath 

Arsenic 
Bismuth 

due      to      an      impurity — 
tellurium 

Garlic 

Onions 

Phosphorus-poisoning 


1202.  Foul  Breath 

Abscess,     Subphrenic 
Hepatic 
opening  into  the  lung 

Actinomycosis 

Alcoholism 

Brominism 


or 


Bronchiectasis 

like  sulphuretted  hydrogen 
Bronchorrhcea 
Cancer  of  Mouth,  Squamous 

„      of  Gullet 
Cancrum  oris 
Caries    of    Jaw,    Nose,    or 

Teeth 
Dilated  Stomach 
Diphtheria 
Empyema 

rupturing  into  lung 

*Faecal  Accumulation 
Follicular  Tonsillitis 
Foreign  Body 

in  nose,  pharynx,  or  larynx 

*Gangrene  of  Lung 
Gangrenous  Sore  Throat 

intense 

Gastritis,  Acute  and  Chronic 
Glossitis 
Gums,  Septic 
Intestinal  Obstruction 
often  stercoral 

Iodism 

Lead -poisoning 

Measles 

Menstruation 

Mercurialism 

Nasal  Obstruction  (580) 

Necrosis  of  Jaw  or  Nose 

Opium  -poisoning 

Otitis  Media 

1198-1202 


BREATH 


337 


Foul  Breath — continued 
*Ozaena 
Peritonitis 

Phosphorus-poisoning 
Phthisical  Cavity 
Pyopneumothorax    with 
Fistula 
*Pyorrhoea  Alveolaris 
Salivation 


Scarlatina 

Scurvy 
*Stomatitis 
♦Teeth,  Foul 

Typhus 

Variola 

Vincent's  Angina 

Cold  Breath  (see  292) 


1202 


338 


BREATHING 


1203.  BREATHING 

The  normal  rate  of  respiration  is  16  to  20  in  the  adult,  44  in 
the  new-born,  and  26  in  a  child  of  five  years.  Expiration  lasts 
a  little  longer  than  inspiration.  The  best  way  to  count  the 
respirations  is  to  place  the  hand  on  the  abdomen,  as  few  people 
breathe  naturally  if  they  know  their  breathing  is  being  watched. 

1204.  Vital  Capacity. — This  is  the  number  of  cubic  inches 
of  air  expelled  from  the  lungs  after  the  maximum  inspiration. 
The  average  for  an  adult  is  225  cubic  inches.  It  is  less  in  the 
recumbent  than  in  the  erect  position,  and  is  increased  more 
by  stature  than  by  chest  measurement.  All  lung  affections 
diminish  it  except  adherent  pleurae. 


1205.  Slow    Breathing 

Ague  (hot  stage) 

Asthma,  Spasmodic  (x) 

Collapse  (235) 
♦Coma  (64) 

Poisoning  by  Aconite,  Anti- 
mony, Chloral,  Chloro- 
form, Opium 

Shock 

Tumour  of  Brain 


1208.  Stertorous  Breathing  or 

Snoring 

This  is  of  two  kinds — 
Nasal,  when  the  soft 
palate  impinges  against 
the  back  of  the  pharynx  ; 
and  Oral,  when  it  remains 
in  contact  with  the  tongue. 
Decubitus  accounts 
largely  for  the  difference. 

Acute  Yellow  Atrophy 
♦Adenoids 

Asphyxia 
♦Coma  (64) 

Concussion  of  Brain 


Epilepsy,  in. 

Fractured  Skull 

Hyper trophied  Tonsils 
♦Narcotic-poisoning 

Nasal  Catarrh 

(Edema  of  Lungs 
♦Paralysis  of  Soft  Palate 

Post-pharyngeal  Abscess 
'  hen-cluck   stertor ' 

Quinsy 

Rhinitis,  Chronic 

Septum,  Deflected 

Uraemia 
hissing 

1207.  Stridulous  Breathing 

Hissing,  squeaking,  or 
whistling  breathing  due 
to  laryngeal  or  tracheal 
stenosis. 

Abscess,  Post-pharyngeal 
Aneurysm,  Thoracic 
Bronchus,  Obstruction  of 
♦Diphtheritic  Laryngitis 
Dryness  of  Vocal  Chords 
Epithelioma,  Local 

1203-1207 


BREATHING 


330 


Strldulous  Breathing — con- 
tinued 
Foreign  Body- 
Glands,  Caseous 

rupturing  into  trachea 
Glands,  Malignant  Cervical 
„        Enlarged  Bronchial 
Hydrophobia 
Hysteria 

ceasing  during  sleep 
Iodism 
*Laryngeal  Spasm 

,,  Tumour 

*Laryngismus  stridulus 
'  child-crowing  ' 
Locomotor  Ataxy 
laryngeal  crisis 

Mediastinal    Growth 
Gidema  of  Larynx 
Paralysis,  Abductor 
Strychnine-poisoning 
Syphilis 
Tetanus 

Thymus,  Enlarged 
Thyroid,  Enlarged 
Tracheal  Stenosis 
'  leopard's  growl ' 

Tracheitis 

Ulcer,  Post-Typhoidal 

,,      Syphilitic 

„      Tuberculous 

1208.  Sighing  Breathing 

Addison's  Disease 
Anaemia  of  Brain 
Collapse   (235) 
♦Dilatation  of  Heart 
Distension  of  Stomach 
Emotion 
Fatty  Degeneration  of  Heart 


z  2 


Lesion  of  Medulla 

Meningitis,  Cerebro-spinal 
„  Simple 

,,  Tuberculous 

Shock 

Spurious  Hydrocephalus 

Syncope 

Tobacco  in  Excess 

1209.  Shallow  Breathing 

Angina  Pectoris 

Broncho-Pneumonia 

Collapse  (235) 
♦Collapse  of  Lungs 

Coma  Vigil  (63) 
♦Fractured  Ribs 

Intercostal  Neuralgia 
♦Intercostal  Paralysis 

„         Rheumatism 

Lead-poisoning 
♦Paralysis  of  Diaphragm 

Peritonitis,   Acute 
♦Pleurisy,  Acute 

„  Diaphragmatic 

Pneumonia,   Acute 

Syncope 

Trance 

1210.  Jerky  Breathing 

Asthma,  Spasmodic 

inspiratory 
♦Chorea 
Gallstones 
Hemiplegia 
Hydrophobia 

inspiratory 
Hysteria 

inspiratory 
Intercostal  Neuralgia 

expiratory 

1207-1210 


340 


BREATHING 


Jerky  Breathing — continued 
♦Laryngismus 
inspiratory 

Myasthenia  Gravis 
Neurasthenia 
Pleurisy,  Acute  (onset) 

expiratory 
Rheumatism  of  Interco stale 

expiratory 
♦Ribs,    Fractured 

expiratory 


1211.  v.  Hasslen's  Breathing 

Expiration  in  jets. 
Trachea,  Compression  of 
as  in  aneurysm,  etc. 


1212.  Irregular  Breathing 

In  '  Biot's  breathing  '  the 
intervals  are  of  varying, 
not  graduated,  length  and 
the  pauses  very  long. 

Apoplexy 

Chorea 

Collapse  (235) 

Collapse  of  Lungs 
pause  after  inspiration 

Hydrocephalus,  Spurious 
♦Lesion  of  Medulla 

Meningitis,  Simple 
♦Meningitis,  Tuberculous 
often  of  '  Biot  type  ' 

Perforation  of  Bowel 

„        of  Stomach 
Rupture  of  Abd.  Viscus 
Shock 
♦Tumour  of  Brain 


1213.  Cyclical  Breathing 

A.  series  of  rapid  regular 
breathings  alternating 
with   long   pauses. 

Meningitis,  Post-basic 

1214.  Cheyne-Stokes' 
Breathing 

After  a  stop,  the  breathing 
is  resumed — faintly  at 
first  and  then  gradually 
increasing  till  it  becomes 
noisy  and  strong.  After 
that  it  gradually  dim- 
inishes till  the  pause 
is  reached.  The  whole 
cycle  lasts  about  1£ 
minutes.  It  may  be 
expressed  in  terms  of 
music  thus  : — 


Ominous,  unless  it  occurs 
during  sleep  only,  and 
this  is  not  very  rare  in 
infants  and  old  people. 
It  is  common  at  high 
altitudes  and  is  always 
associated  with  a  high 
tension  pulse. 

Aortic  Aneurysm 

Apoplexy  (term.) 

Arterio-sclerosis 

Caisson  Disease 

Cholera 
♦Diabetes,  in. 

Diphtheria 

Embolism 
♦Fatty  Degeneration  of  Heart 

Fibroid  Heart 

General  Paralysis 

Haemorrhage,  Severe 

Hydrocephalus,  in. 

Influenza 

Int.  Spinal  Meningitis 

Lung,  Fibroid 

1210-1214 


BREATHING 


341 


Cheyne-Stokes'     Bkeathing 
— continued 
Meningitis,  Simple,  in. 

„  Tuberculous,  in. 

Narcotic-poisoning 
Nephritis,  Acute 

„  Chronic 

Pneumonia 
Senile  Decay 
Septicaemia 
Softening  of  Brain 
Tumour  of  Brain 
♦Typhic  State  (62) 
Uraemia 

Valvular  Disease 
Variola 

1215.  Duckworth's  Sign 

An  apparently  complete 
stoppage  of  breathing 
several  hours  before  the 
heart  has  ceased  to  beat. 

Intracranial  Pressure 

1216.  Simon's  Sign 

A  dissociation  of  the  move- 
ments of  the  diaphragm 
from  those  of  the  thorax. 

Meningitis,  Incipient 
children 

1217.  Inverted  Type 

Inspiration  being  longer 
than  expiration 

Pneumonia 
in  children 

1218.  Thoracic  Breathing, 
Marked 

Abdominal  Tumours 
Ascites 


Diaphragm,  Tonic  Spasm  of 
*Diaphragmatic  Pleurisy 

Emphysema 

Meteorism 

*Paralysis  of  Diaphragm 
*Perforation  of  Stomach   or 
Intestine 

Pericardial  Effusion,  Large 

Pericarditis,  Acute 
*Peritonitis,  Acute 

Pregnancy 

Rupture  of  Abd.  Viscus 

1219.  Abdominal      Breathing, 
Marked 

Fractured  Ribs 
*  Pleurisy,  Double 

Pneumonia,  Double 

Spinal  Paralysis 
cervical  lesion 

Strychnine-poisoning 
*Tetanus 


1220.  Suffocative  Breathing 

Angio-neurotic  (Edema 
laryngeal 
*Diphtheritic  Laryngitis 
Displacement  of  Heart 

,,  of  Trachea 

Fatty  Degeneration  of  Heart 
*Foreign  Body  in  Air- passages 
*Hydrophobia 
Laryngeal  Growths 
(Edema  Laryngis 
Strychnine-poisoning 
Syphilitic  Laryngitis 
on  eating 

Tetanus 

Tuberculous  Laryngitis 
on  eating 

1214-1220 


342 


DYSPNOEA 


1221.  DYSPNCEA 

Dyspnoea  may  be  divided  into  haemic  and  aerial — haemic, 
when  insufficient  haemoglobin  reaches  the  air-cells  of  the  lung, 
as  in  anaemia  ;  aerial,  when  insufficient  air  or  oxygen  reaches 
the  blood  in  the  air-cells,  as  in  lung  diseases.  In  either  case 
the  difficulty  is  surmounted  more  or  less  by  increased  rapidity 
of  respirations.  Inspiratory  dyspnoea  is  commonly  the  result 
of  obstruction  in  the  air-passages  :  expiratory,  of  affections  of 
the  air-cells,  especially  emphysema.  There  is  also  reflex  dyspnoea 
(tachypncea),  to  which,  I  think,  attention  has  not  been  directed. 
It  occurs  chiefly  in  infants,  and  especially  in  connection  with 
teething  :  the  rapid  breathing  (60  to  80  per  minute)  may  easily 
mislead,  but  it  is  quite  independent  of  lungs  or  blood.  Allied 
to  this  is  the  emotional  dyspnoea  of  hysteria  etc.  Pain  some- 
times causes  dyspnoea  by  interfering  with  deep  breathing. 

Leukaemia 
Lymphadenoma 
*Malformation  of  Heart 


1222.  Dyspnoea  on  Exertion 

As  great  exertion  will 
produce  dyspnoea  in  the 
strong,  so  slight  exertion 
will  produce  it  in  the 
weak. 

Addison's  Disease 

Adenoids 
*Anaemia 

Aortic  Regurgitation 

Bradycardia 

Cardiac  Asthma 

Chlorosis 

Cirrhosis  of  Liver 

Dilatation  of  Stomach 

Exophthalmic  Goitre 
*  Fatty  Degeneration  of  Heart 
especially  on  ascents 

Fibroid  Heart 
Goitre 
Hooping  Cough 

after  paroxysm 
Hypertrophy  of  Heart 
Influenza 
Laryngitis,  Chronic 


Myasthenia  Gravis 
Neurasthenia 
*Obesity 
Pernicious  Anaemia 
Pyrexia 
Rickets 
Scurvy 

1223.  Dyspnoea,  General 

Ac.  Ascending  Paralysis 
Ague  (cold  stage) 
Aneurysm  of  Heart 
Angina  Ludovici 
Aortic  Aneurysm 
Aortitis,  Acute 
Arterio-sclerosis,  in. 
Asthma,  Cardiac 

chiefly  inspiratory 
Asthma,  Spasmodic 

expiratory 
Ascites,  in. 
Beri-beri 

1221-1223 


DYSPNOEA 


343 


Dyspncea,  General — contd. 
*Bronchitis.  Acute 

„  „      Capillary 

,,  Chronic 

Broncho-pneumonia 
Bronchorrhcea 
Bronchus,  Plugged  or  Com- 
pressed 
Cancer  of  Larynx 

of  Lung 
Cirrhosis  of  Lung 
Collapse  of  Lungs 
Congestion  of  Lungs,  Hypo- 
static 
Conium-poisoning 
Cor  Bovinum 
Crico- arytenoid  Ankylosis 
,,  Arthritis 

Diabetic  Coma 

'  air     hunger  ' — deep,     not 
rapid,  breathing 

Diaphragm,  Tonic  Spasm  of 
Diaphragmatic  Hernia 
„  Paralysis 

,,  Pleurisy 

Dilatation  of  Heart 
*Displacement  of  Heart 
Dissecting  Aneurysm 
Emphysema 
expiratory 

Empyema 
Endocarditis,  Acute 
Enteric  Fever 
Exophthalmic  Goitre 
Faecal  Accumulation 

only  if  heart  is  displaced 

Fat  Embolism 
Fatty  Heart 
Fibroid  Heart 

Foreign  Body  in,  or  pressing 
upon,  the  air  tubes 


Gangrene  of  Lung 

Glanders 

Glands,  Malignant  Cervical 

Glossitis,  Acute 

Growths,  Laryngeal 

Heart,  Gouty 

Hepatic  Abscess 

of  upper  surface 
Hepatitis,  Acute 
Hydatids  of  Liver 

if  large 

Hydatids  of  Lung 

Hydrothorax 

Hyperpyrexial  Sunstroke 

Hysteria 

Intercostal  Neuralgia 
*Intercostal  Rheumatism 

Laryngeal  Polypus 

„  Tuberculosis 

Laryngismus  Stridulus 

Laryngitis,    Acute 
*Laryngitis,  Diphtheritic 
inspiratory 

Laryngitis,  Tertiary    Syphi- 
litic 
Locomotor  Ataxy 

inspiratory — laryngeal  crisis 
Lymphadenoma 

pressure  of  glands 
Measles 

Mediastinal  Abscess 
„  Tumour 

Meningitis,  Cerebro -spinal 
,,  Spinal 

cervical  portion 
*Mitral  Disease 
Myelitis,  Cervical 
*  (Edema  of  Larynx 
,,    of  Lungs 
(Esophageal  Tumour 

1223 


344 


DYSPNCEA 


Dyspncea,  General — contd. 

Paralysis  of  Posterior  Crico- 
arytenoid 
inspiratory 

Pericarditis 

Pericardium,  Adherent 

Peritonitis 

Pleurisy,  Acute 

Pneumonia,  Acute 

Pneumoperitoneum 

Pneumothorax 

Post-pharyngeal  Abscess 

Pulmonary  Apoplexy 
sudden 

Quinsy 

Relapsing  Fever 

Spasm  of  Larynx  (insp.) 

Stenosis  of  Larynx 
*Stenosis  of  Trachea 

Syphilitic  Heart 

Syringomyelia  (insy.) 

Thrombosis    of    Pulmonary 
Artery 

Thymus,  Enlarged 

dyspnoea      increased     with 
chin  up 

Thyroid,  Enlarged 
Tuberculosis,  Acute 
Tumours,  Large  Abdominal 
Uraemia 

1224.  Orthopncea 

Inability  to  breathe  lying 
down. 

Acute  Dyspnoea  (1223) 

from  causes 
which  interfere  with  the 
expansion  of  both  lungs, 
such  as  double  hydro  - 
thorax  or  acute  tym- 
panites ;  from  obstructed 
tubes  or  air-cells,  as  in 
spasmodic  asthma,  double 
pneumonia,  etc. ;  or  from 


***  Especially 


interference  with  the  pul- 
monary circulation,  as 
expressed  by  the  cyanosis 
of  mitral  regurgitation. 
(See  Decubitus,  1281) 

1225.  Paroxysmal  Dyspncea 

Acidosis 
Angina  Pectoris 
Aortic  Aneurysm 
*  Asthma,  Spasmodic 
expiratory 
Bronchial  Glands,  Enlarged 
Broncho-pneumonia 

*  Cardiac  Asthma 
Cirrhosis  of  Kidney 
Compression  of  Trachea 

*  Embolism     of     Pulmonary 

Artery 
Foreign  Body  in  Air- passages 
Hydrophobia 
Laryngeal  Polypus 
Laryngismus  Stridulus 
Laryngitis,  Acute 
*Laryngitis,  Diphtheritic 
Locomotor  Ataxy 
laryngeal  crisis 

Lymphadenoma 
Malformation  of  Heart 
Mediastinal  Tumour 
Myasthenia  Gravis 
(Edema  Laryngis 
,,     of  Lungs 
*Plastic  Bronchitis 
Strychnine-poisoning 
Tetanus 
Tetany 

Thymus,  Enlarged 
Thyroid,  Enlarged 
Trichinosis 
Uraemia 
Uvula,  Elongated 

1223-1225 


THE   VOICE 


345 


1226.  THE  VOICE 


1227.  Voice  Lost  (Aphonia) 

Acute  Ascending  Paralysis 

Aortic  Aneurysm 

Bronchial  Glands,  Enlarged 

Cholera 

Contracted     Cicatrices      on 
Vocal  Cords 

Coryza 
*Diphtheritic  Laryngitis 

Excessive  Vocal  Exertion 

Exhaustion 

Exophthalmic  Goitre 

Foreign  Body 
♦Growths,  Laryngeal 
*Hysteria 

Insanity 
♦Laryngitis,  Chronic 

Lead  Palsy 

Lupus  of  Throat 

Mediastinal  Tumour 
or  cracked 

GEdema  Laryngis 
Paralysis    of    Adductors, 

Bilateral 

or  weak 

Pericardial  EffusioD,   Large 
Post-pharyngeal  Abscess 
Rheumatoid  Arthritis 
♦Syphilis 
Trichinosis 
Violent  Emotion 


1228.  Weak  Voice 

Bulbar  Paralysis 
Cholera 

Paralysis  of  Adductors,    Bi- 
lateral 


Paralysis     of     Recurrent 

Laryngeal 

monotonous,  if  both; 
cracked  on  exertion,  if 
only  one 

♦Prostration 
Tracheotomy 

or  other  open  wound  of 
trachea 

Tuberculous  Laryngitis 

1229.  Hoarse  Voice 

Acromegaly 

Alcoholism 

Aortic  Aneurysm 

Bronchial  Glands,  Enlarged 

Bronchitis,  Acute,  I. 

Cancer  of  Larynx 

Cholera 

Chorditis  tuberosa 
♦Congestion  of  Larynx 

Crico-ary  tenoid  Ankylosis 
,,  Arthritis 

♦Diphtheritic  Laryngitis 

Enteric  Fever  (x) 
1  laryngotyphus ' 

Exophthalmic  Goitre 

Follicular  Pharyngitis 

Granular  Pharyngitis 
♦Growths,  Laryngeal 

Laryngitis,  Acute 
„  Chronic 

„  Syphilitic 

♦Laryngitis,  Tuberculous 

Measles 

Myxcedema 
leathery 

Pachydermia  Laryngis 

1226-1229 


346 


THE  VOICE 


Hoarse  Voice — continued 
Paralysis  of  Superior  Laryn- 
geal Nerve 
Perichondritis  Laryngea 
Post-pharyngeal  Abscess 
Syphilis 

1230.  Nasal  Voice 

The  nasal  voice  due  to 
blocking  of  the  nose  is  less 
hollow  than  that  due  to 
cleft,  paralysed,  or  per- 
forated palate. 

*Adenoids 

Bulbar  Paralysis 

Cleft  Palate 
*Coryza 

Diphtheritic  Paralysis 

Hay  Asthma 
*Hypertrophied  Tonsils 

Myasthenia  Gravis 

Paralysis  of  Soft  Palate 

Perforate  Palate 

Pharyngitis,  Acute 
*Polypus,  Nasal 

Post-pharyngeal  Abscess 

Quinsy 

Septum,  Excentric 

Typhus  (prodr.) 

Variola  (prodr.) 

| 

1231.  High-pitched  Voice 

Cleft  Palate 

Hereditary  Cerebellar  Ataxy 
guttural  or  cracked 

*High  Palatine  Arch 
Palate,  Perforate 
Paralysis  Agitans 

„      of  both  Abductors 
Senility 


1232.  Shrieks  and  Cri  Hydren- 
cephalique 
Anaemia  of  Brain 
Epilepsy  (onset) 
*Hydrocephalus,  Acute 

,,  Spurious 

Hysterical  Convulsions 
*Night  Terrors 
Nightmare 
Pain 
Tuberculous   Meningitis 


1233.  Cry  of  Infants 

Colic 

furious,  with  knees  drawn 
up 

Collapse  of  Lung 

whining 
Diphtheria,  II. 

aphonic 
Dyspnoea,  Acute 

absent 
Earache 

continuous 

Hereditary  Syphilis 

hoarse,  high  pitched 

Teething 

intermittent ;     with   fingers 
in  mouth 


1234.  Laughter,   Uncontroll- 
able 

Disseminated  Sclerosis 
Hysteria 


1229-1234 


SPEECH 


347 


1235.  SPEECH 


1236.  Speech  Absent  (Mutism) 
Aphasia,  Complete  Motor 

except  a  few  sounds 

Bulbar  Paralysis,  in. 

Complete  Deafness 

if  supervening  before  the 
sixth  year 

Dementia 
Glossitis,  Acute 
Hysteria 
Idiocy 
Malingering 
Melancholia 
Softening  of  Brain 
Thrombosis  or  Embolism  of 
Middle  Cerebral  Artery 

1237.  Speech  Indistinct 
*Alcoholism 

Bromism 
Glossitis 
Hysteria 
*Mouth,  Dryness  of 
Mumps 
Quinsy 
Toothlessness 
Typhic  State  (62) 

(See  Dysarthria,  1239) 

1238.  Differential 

In  '  scanning  speech  '  each 
syllable  is  pronounced 
separately  and  deliber- 
ately ;  '  slurred  speech  ' 
is  like  that  of  a  drunken 
man  ;  '  lalling  speech' 
is  baby  talk  ;  in  '  stumb- 
ling speech  '  syllables  are 
duplicated: 

Acute  Dyspnoea  (1223) 

interrupted 


Aphasia  (see  1241) 

Bulbar  Paralysis 

linguo -dentals  lost  first, 
then  labials 

Chorea 

hesitating  and  jerky 
Disseminated  Sclerosis 

slow  and  scanning 
Epilepsy 

monotonous 

Facial  Paralysis 

labials  and  u,  o,  and  oo, 
unsounded 

Friedreich's  Disease 

'  scanning  ' 

General  Paralysis 

slow,  slurred  and  inter 
rupted 

Hereditary  Cerebellar  Ataxy 

accented  syllables  and  alter- 
nations of  pitch 

Idiocy 

lalling 
Paralysis  Agitans 

first  hesitating,  then  hurried 

1239.  Anarthria    and    Dysar- 
thria 

In  anarthria,  though  the 
power  of  correct  speech 
may  be  lost,  the  patient 
understands  what  is  said 
to  him,  and  can  both 
read  and  write. 

Lesion  of  lenticular 
nucleus  or  of  knee  of 
internal  capsule  (anterior 
part). 

Dysarthria  may  be  either 
paralytic  or  ataxial. 

1235-1239 


34S 


SPEECH 


Anarthria  and  Dysarthria 
— continued 

Acute  Ascending  Paralysis 

Amyotrophic  Lateral 
Sclerosis 

Ataxic  Paraplegia 

Bulbar  Paralysis 

Disseminated  Sclerosis 

Facial  Paralysis,  Double 

Friedreich's  Disease 

General  Paralysis 

Hemiplegia 

Idiopathic  Muscular  Atro- 
phy 

Meningitis,  Gummatous 

Myasthenia  Gravis 
Myelitis 

Neuritis,  Multiple 
Paralysis,  Diphtheritic 
,,  Hypoglossal 

Progressive  Muscular  Atro- 
phy 
Pseudo-bulbar  Paralysis 

Functional  Dysarthria 
occurs  in  alcoholism,  nar- 
cotic poisoning,  etc.,  as 
well  as  in  stammerers. 

APHASIA 

Aphasia  is  of  two  kinds — 
Sensory  and  Motor. 

1240.  Sensory  Aphasia 

This  is  divided  into  Auditory 
or  Word  Deafness;  and 
Visual  or  Word  Blindness. 

In  Auditory  Aphasia  the 
lesion,  is  in  the  temporal 
cortex.  The  patient  is 
unable  to  recognise  the 
meaning  of  spoken  lan- 
guage ;  but  he  is  still 
able  to  read  and  to  under- 
stand what  is  written. 


In  Visual  Aphasia  or 
Alexia  the  lesion  is  in 
the  left  angular  gyrus, 
The  patient  is  unable  to 
write  (agraphia)  and  ho 
cannot  copy ;  but  he 
can  understand  spoken 
words  and  his  speech  is 
not  much  affected. 

1241.  Motor  Aphasia 

In  this  the  lesion  is  (pace 
Marie)  in  the  third  frontal 
convolution.  The  patient 
is  quite,  or  nearly,  unable 
to  speak  or  write ;  but  his 
intelligence  is  temporarily 
clear,  and  he  understands 
what  is  said  to  him.  If 
he  uses  words  wrongly,  he 
is  conscious  of  the  error. 

The  commonest  cause  of 
Aphasia  is  blocking  of 
the  middle  cerebral  artery. 
If  the  whole  artery  is 
obstructed,  there  will  [be 
both  motor  and  sensory 
aphasia  as  well  as  hemi- 
plegia. 

Abscess  of  Brain 
*Embolism 

Encephalitis 

Fracture  of  Skull 

Gumma 

Haemorrhage,  Cerebral 

Meningitis 

Syphilitic  Endarteritis 
*Thrombo3is 

Tumour  of  Brain 

1242.  Transient  Aphasia 

Arterio-sclerosis 
Epilepsy,  Post- 
Hysteria 

General  Paralysis 
Migraine 
Neurasthenia 

1239-1242 


SPEECH 


349 


Pregnancy 
Raynaud's  Disease 
Syphilis 
Uraemia 

Transient  aphasia  also 
follows  frights  and  ex- 
haustion, and  occurs  in 
poisoning  by  santonin, 
belladonna,  stramonium, 
and  snake  venom. 


Allied  to  Aphasia  and  An- 
arthria  are  the  following  : 

1243.  Aphemia 

An    inability    to  utter    the 
right  word. 


1244.  Paraphemia 

The     employment 
wrong  word. 


of    the 


1245.  Apraxia,  Sensory 

Failure  to  recognise  a 
familiar  object ;  thus  he 
may  try  to  write  with  a 
tooth  brush.  It  is  com- 
mon in  tumour  of  the 
corpus  callosum.  Allied 
to  this  is  Mind  Blindness, 
the  subject  of  which  fails 
to  recognise  faces,  etc. 

1246.  Apraxia,  Motor 

Inability  to  perform  certain 
familiar  movements  in  a 
non-paralytic  person. 

1247.  Asymbolia 

Inability  to  understand 
symbols. 

1248.  Amimia 

Loss  of  power  to  express 
meaning  by  gesture. 


1249.  Paramimia 

Use  of  the  wrong  gesture, 
as  nodding  for  '  no.' 

1250.  Amusia 

Loss  of  a  previous  appreci- 
ation of  music. 

There  are  also  mental  con- 
fusions of  taste  and  smell. 

1251.  Folie  de  Pourquoi 

Incessant  asking  of  ques- 
tions (in  an  adult). 

Psychasthenia 

1252.  Echolalia 

Persistent  repetition  of  the 
same  word. 

Hysteria 

Latah 

occurs  in  Java 

1253.  Coprolalia 

Involuntary  and  explosive 
use  of  bad  language 

*Gilles  de  la  Tourette's  Dis- 
ease 
Hysteria 

1254.  Bradylalia 

Slow  speech  (see  1238) 

1255.  Idioglossia 

The   vowel  sounds  are  cor 
rect,    but   the   consonant 
sounds  are  confused. 

Idiocy 

But  it  is  common  in  back- 
ward children,  and  these 
gradually  grow  out  of  the 
peculiarity. 


1242-1255 


350 


HANDWRITING 


1256.  HANDWRITING 

The  writing  centre  has  been  assigned  to  the  posterior  portion 
of  the  second  frontal  convolution,  but  many  authorities  deny  its 
existence. 


1257.  Altered  Writing 

Alcoholism 
shaky 

*  Aphasia  (1240) 

first  degree  tremulous 
with  omission  of  letters  ; 
second  degree  lost,  with 
exception  of  a  name  or 
a   few   words    (agraphia) 

Chronic  Softening 

Diphtheritic   Paralysis 

and  other  paralyses  when 
affecting   hand 

Disseminated  Sclerosis 
vibratile 

*General  Paralysis  of  Insane 

upstrokes  shaky,  letters  not 
joined 

Senile  Atrophy 

Writer's  Cramp,  and  other 

technic  paralyses  of  hand 

The  handwriting  is  also 
necessarily  affected  by 
disablement  of  the  hand 
from  gout,  rheumatoid 
arthritis,  surgical  affec- 
tions, etc. 


1258.  Paragraphia 

The  writing  of  wrong  letters, 
syllables,  or  words. 

1259.  Agraphia 

Inability  to  write  the  word 
desired.  Common  in  the 
aphasia  of  migraine. 

1280.  Mirror- Writing 

Only  legible  when  held 
before  a  mirror. 

The  left  hand  is  used  for  this 
test.  The  symptom  is 
present  in  25  per  cent,  of 
healthy  persons  over  15. 

Aphasia  (1240) 

especially  in  the  left-handed 

Hemiplegia 

Hysterical  Aphasia  (x) 
Imbecility  (x) 
Infantile    Cerebral    Haemor- 
rhage 
Locomotor  Ataxy  (x) 


1256-1260 


THE   INTELLECT 


351 


1261.  THE  INTELLECT 

Unaccustomed  environment  may  give  a  false  impression  of 
dulness.  As  the  sheep  is  clever  enough  on  its  ancestral  mountains, 
but  is  dull  on  the  plains,  so  the  yokel  seems  dull  in  a  town  and  the 
townsman  scarcely  less  so  in  the  country.  Deafness  also  gives  a 
false  impression  of  dulness. 


1262.  Dull  (Hebetude) 
Absinthism 
Achondroplasia 
Acromegaly 
*Adenoids 

*  Alcoholism,  n. 
Anaemia  of  Brain 
Aphasia 
Arterio- sclerosis 
Ataxic  Paraplegia,  n. 
Atrophy  of  Brain 
Bromism 

Cerebral  Diplegia 
Cerebro-spinal  Meningitis,  i. 
Cervico-occipital    Neuralgia 
Chorea 
*Cretinism 

Disseminated  Sclerosis 
Dysentery 

Effusion  into  Ventricles 
Encephalitis 
Enteric  Fever 

*  General  Paralysis  of  Insane 
Haematoma  of  Dura  Mater 
Hereditary  Cerebellar  Ataxy 
Huntington's  Chorea 
Hydrocephalus,  Chronic 

,,  Spurious 

Hyperpyrexia 
Hypertrophy  of  Brain 
Infantile  Hemiplegia 
Meningitis,  Chronic 
Myoclonus  Epilepticus 


*Myx  oedema 

slow  cerebration 

Neurasthenia 
Paranoia,  I. 
Pseudo-hypertrophic    Para 

lysis 
Recklinghausen's  Disease 
Relapsing  Fever 
Senile  Atrophy 
*Sof  tening  of  Brain 
Starvation 

Thrombosis  of  Cerebral  Ar- 
teries 
Trypanosomiasis 
Tumour   of   Brain,    Frontal 
Typhus 

from  commencement 
Uraemia 

1263.  Dementia 

Alcoholism 

Amaurotic  Family  Idiocy 
Atrophy  of  Brain 
Dementia  Precox 
General  Paralysis 
Huntington's  Chorea,  n. 
Paranoia 
Senility 

Softening,  Cerebral 
Syphilis,  Cerebral 
Tumour  of  Brain 
esp.  of  c.  callosum 

1261-1263 


352 


THE   INTELLECT 


1264.  Precocious  Mentality 

This  has  been  observed 
in  Coeliac  Disease  and 
is  not  uncommon  in  the 
tuberculous. 


1265.  Loss    of    Memory 
(Amnesia) 

Including  impaired  memory 
(hypomnesia). 

Apoplexy 

Arterio-sclerosis  of  Brain 
Atrophy  of  Brain,  Senile 
Bromism 
Dementia 

'  Dual  Personality  ' 
Embolism 
Epilepsy 

General  Paralysis  of  Insane 
Hsematoma  of  Dura  Mater 
Hydrocephalus 
Hysteria 
*Injuries,  Head 
Korsakoff's  Syndrome 
Meningitis,  Chronic 
Multiple  Neuritis 
Senile  Decay 
for  recent  events 

Syphilitic  Disease  of  Brain 
Thrombosis      of      Cerebral 

Vessels 
Toxaemia 
Tumour  of  Brain 

esp.  of  temporo-sphenoidal 
lobe 
%*  Other  affections  of  memory 
are  Amnesia  Verbalis, 
f orgetfulness  of  words ; 
and  '  Hypermnesia,'  an 
uncannily  good  memory 
for  trifles  met  with  among 
the  insane. 


1266.  Paramnesia 

The    patient    '  remembers 
events    that    never    hap 
pened.     George    IV.,   forr 
instance,    frequently    de 
scribed  how    he  led   the 
cavalry  at  Waterloo. 

The  condition  differs  from 
lying  in  that  the  patient 
is  absolutely  convinced 
of  the  truth  of  his  state- 
ment. 

Hysteria 

Korsakoff's  Syndrome 
♦Petit  Mai 


1267.  Aprosexia 

Inability  to  fix  the  attention. 
Adenoids 
Coryza 
Insanity 
Nasal  Catarrh 
Naso- pharyngeal  Catarrh 
Neurasthenia 

(See  Dulness,  1262) 

1268.  Abulia 

(Loss  of  Will  Power) 

This  occurs  notably  in 
alcoholics  and  habitual 
drug  takers. 

1269.  Illusions  or  Hallucina- 
tions 

When  an  object  is  mistaken 
for  something  else,  as  a 
pig  for  a  cat,  it  is  an 
illusion ;  when  something 
is  seen  where  nothing  is 
visible,  it  is  a  hallucina- 
tion. Hallucinations  may 
be  of  sight,  hearing,  taste; 
smell,  feeling  and  even 
of  muscular  sense. 

1264-1269 


INTELLECT 


353 


Illusions     or     Hallucina- 
tions— continued 
Absinthism 
Aura  epileptica 
Bell's  Mania 
'  Day  Terrors  ' 
*Delirium  Tremens 
Ergotism 

Exanthemata,  Acute 
General  Paralysis  of  Insane 
Hydrophobia 
Hyperemia  of  Brain 
Hyperpyrexia 
Hysteria 

Korsakoff's  Syndrome 
Multiple  Neuritis 
Myxcedema 
Narcotics 
'  Night  Terrors  ' 
Paranoia 
Tumour  of  Brain 

esp.  of  temporo-sphenoidal 
lobe 

Typhic  State  (62) 


1270.  Delusions 

In  addition  to  the  common 
delusion  of  persecution, 
wickedness,  ruin,  etc., 
others  of  sleeplessness, 
constipation,  and  starva- 
tion are  found. 

*Delirium  Tremens 

Dementia 

General  Paralysis  of  Insane 

Hypochondriasis 

Hysteria 

Mania 

Melancholia 

Myxcedema,  m. 
♦Paranoia 


1271.  Delirium 

Delirium  is  of  two  kinds,  the 
wild  and  active  variety, 
in  which  the  patient  may 
have  to  be  held  down ; 
and '  muttering  delirium,' 
in  which  he  lies  inert, 
mumbling  to  himself.  A 
delirious  patient  usually 
imagines  himself  to  be 
following   his  occupation. 

Patients  with  a  personal  or 
family  history  of  mania 
easily  become  delirious. 

Absinthism 

Acute  Yellow  Atrophy 
Alcoholism,  Acute 
delirium  '  a  potu  ' 

Anaemia  of  Brain,  Chronic 
Bell's  Mania 

Capillary  Bronchitis,  in. 
Cerebral  Haemorrhage,  n. 
Cerebro-spinal  Meningitis 
Cholangitis,  Chronic  Fibrous 
Chorea,  Severe 
*Delirium  Tremens 

i.  noisy ;    n.  mumbling 

Dysentery 
Dysmenorrhea  (x) 
Encephalitis 
Enteric  Eever 
Erysipelas 
Exanthemata,  Acute 

praam,  in  children 
Gangrene  of  Lung 

muttering 

Glanders 
Haemorrhage 
Hydrophobia 
Hyperaemia  of  Brain 
Hyperpyrexia  (297) 
2  a  1269-1271 


354 


INTELLECT 


Delirium — continued 
Influenza 

Intermittent,  Pernicious 
Korsakoff's  Syndrome 
Labyrinthitis,  Acute 
*Mania 
Measles 
Meningitis 
Myocarditis,  Acute 
Pneumonia,  Acute 
Remittent  Fever 
Rheumatism,  Acute 
Scarlatina 
Septicaemia 
Trichinosis 
Tuberculosis,  Acute 


♦Typhic  State  (62) 
muttering 

Typhus 
muttering 

*  Uraemia 
Variola 
Weil's  Disease 

Delirium  is  also  occasioned 
by  drugs  —  belladonna, 
cannabis  indica,  chloro- 
form, hyoscyamus, 
morphia,  and  synthetic 
salicylates.  Severe  pain 
and  shock  will  also  cause 
it. 


1271 


THE  EMOTIONS 


355 


1272.  THE  EMOTIONS 


1273.  Excitement  and  Exalta- 
tion 

Anaemia  of  Brain 
Bell's  Mania 
Friedreich's  Paralysis 
General  Paralysis,  i. 
sometimes  n. 

Hyperemia  of  Brain 
♦Mania,  Acute 
Paranoia,  m. 
Tumour      of     Temporo- 

sphenoidal  Lobe 
Action  of — 
*Alcohol,  i. 

Amylene 

Aniline 

Chloroform 

Creasote 

Nitroglycerin 

Turpentine 
(See  Delirium,  1271) 

1274.  Depression   and  Melan- 
choly 

Angina  Pectoris 
Atony  of  Stomach 
*Bromism 
Bulbar  Paralysis 
Disseminated  Sclerosis 
Duodenal  Catarrh 
Dysentery 
Enteroptosis 
Gastritis,  Chronic 
General  Paralysis,  n. 

sometimes  i. 
Huntington's  Chorea 
Hydrophobia 
Hypochondriasis 


Hysteria 
Iodism 

Jaundice  (392) 
♦Membranous  Colitis 
Menopause 
Mercurialism 
♦Mucous  Colitis 
Neurasthenia 
Paranoia,  i. 
Pernicious  Anaemia 
Poisoning  by — 

Aconite 

Calabar  Bean 

Hemlock 

Lobelia 

Tartar  Emetic 

Tobacco 
Softening,  Cerebral 
Tumour  of  Brain 

esp.   of  temporo-sphenoidal 
lobe 

1275.  Alternating 

(between  very  high  and  very 
low  spirits) 

Bulbar  Paralysis 
Chlorosis 

Disseminated  Sclerosis 
♦Hysteria 
Menopause 
Neurasthenia 
Pregnancy 
Softening,  Chronic 

1276.  Witzelsucht 

Perpetually  '  trying  to  be 
funny.' 

Tumours,    Cerebral 
frontal  or  temporal 
Needless  to   say   it   is   not 
always  pathological. 

a  2  1272-1276 


356 


THE   EMOTIONS 


1277.  Change  of  Temper 

An  amiable  person  becoming 
bad  tempered  and  vice 
versa. 

Aura  epileptica 

Enteric  Fever,  n. 

Exophthalmic  Goitre 
♦General  Paralysis 

Melancholia 
♦Pregnancy 

1278.  Irritability 

Ranging  from  quendous- 
ness  to  fits  of  violent 
anger. 

Acromegaly 
Alcoholism,  Chronic 
Anaemia  of  Brain 
Catalepsy  (praem.) 
Diabetes 

Dilatation  of  Heart 
Duodenal  Catarrh 
Encephalitis,  i. 
Exophthalmic  Goitre 


General  Paralysis 
*Gout 

Lead  Poisoning 

Hyperaemia  of  Brain 

Hypertrophy  of  Brain 

Jaundice  (392) 
♦Lithaemia 

Malformation  of  Heart 

Menopause 
♦Mental  Strain 

Myxcedema,  in. 

Nephritis,  Chronic 

Neurasthenia 

Rheumatism 

1279.  Deterioration  of  Conduct 

In  those  who  are  past  their 
youth. 

Alcoholism 
General  Paralysis 
an  early  sign 

Insanity 
Morphinomania 


1277-1279 


OBSESSIONS 


357 


1280.  OBSESSIONS 

These  differ  from  delusions  in  that  the  patient,  although  unable 
to  resist  the  ideas,  yet  fully  recognises  them  as  morbid.  Dr. 
Johnson's  habit  of  touching  every  post  in  his  path  comes  under  this 
heading. 


Acrophobia 

Fear  of  Heights 

Agoraphobia 

Fear  of  Space,  Bridges,  etc. 

It  occurs  in  Ankylosis  of  the 
Stapes. 

Aichmophobia 
Fear  of  Sharp  Objects 

Anthropophobia 

Dislike  to  Society 

Arithmomania 
Mania  for  Counting 

Calisophobia 

Inability  to  sit  quiet 

Claustrophobia 

Fear  of  Closed  Spaces  such 
as  Railway  Compartments 


Ereuthophobia 

Fear  of  Blushing 

Monophobia 

Fear  of  Solitude 

Mysophobia 

Fear  of  Dirt 

Pathophobia 

Fear  of  Disease 

Toxieophobia 

Fear  of  Being  Poisoned 

All    the    above    symptoms 
point  to — 

Psychasthenia,    which   may 
lead  on  to  Paranoia 


Folie  de  Pourquoi  (1251) 


1280 


358 


DECUBITUS 


1281.  DECUBITUS    OR    POSTURE  IN  BED 


1282.  Orthopnoea 

Inability  to  breathe  except 
in  the  upright  position. 

Severe   Dyspnoea 
(See  1223) 

1283.  Right  Side 

Cavity  in  Lung 
with  orifice  to  left 

Cirrhosis  of  Right  Lung 
Collapse  of  Right  Lung 
Left  Acute  "Pleurisy,  I. 
Right  Pleural  Effusion 

„      Pneumothorax 
Sciatica,  Left 

1284.  Left  Side 

Cavity  in  Lung 

with  orifice  to  right 
Cirrhosis  of  Left  Lung 
Collapse  of  Left  Lung 
Left  Pleural  Effusion 

„     Pneumothorax 
Pericardial  Effusion,  I. 
Right  Acute  Pleurisy,  I. 
Sciatica,  Right 

1285.  Coiled  up  on  Side 
Affections   of   Brain   or   its 

Membranes 
Hepatic  Colic 
Meningitis 
Renal  Colic 
Tumour  of  Middle  Cerebellar 

Peduncle 


1286.  Back  with  Knee  Flexed 

Appendicitis 

right  knee  only 
Hip   Disease 

one  knee 
Pelvic  Cellulitis 

one  knee 

Pericarditis,   Acute 
Perihepatitis 
♦Peritonitis 

both  knees 


1287.  On  Chest  and  Abdomen 

Aneurysm  (x) 
Caries,   Vertebral 


1288.  On     Knees     with  Head 
Downwards 

Aneurysm  of  Heart 
Mediastinal  Disease 


1289.  Stocker's  Sign 

The  patient  resists  any 
attempt  to  pull  down  the 
bedclothes. 

Tuberculous  Meningitis 

In  typhoid  no  notice  is 
taken  of  the  attempt. 


1281-1289 


THE   GAIT 


359 


1290.  THE  GAIT 


1291.  Limping 

Abscess,  Inguinal 
„         Pelvic 
„         Perinephric 
Aneurysm 
Ankle  Affections 
Appendicitis,  i. 
Corns,  Callosities,  etc. 
Coxa  valga 
Gout 

Heel,  Sore 
Hip  Disease 

pelvis  fixed 
Inflammatory  Affections  of 

Limb 
Injuries  to  Limb 
Intermittent  Limp 

Charcot's  '  Claudication ' 
Knee  Affections 
Metatarsal  Neuralgia 
Myelo-sarcoma 
Myositis 
Phlebitis 
Rheumatism 
Sacro-iliac  Disease 

opposite  shoulder  raised 
Sciatica 

pelvis  often  fixed 
Shortening  of  one  Limb  (852) 
Sprains 
Unilateral  Paralysis 

(See  Foot,  Dragged,  1298) 

1292.  Dysbasia  Angio-Sclero- 
tica  ('  Claudication  Inter- 
mittente ') 

Abdominal  Aneurysm 

„  Angina 

Arterio-sclerosis 


Aneurysm,  Poplitaeal 

Syphilis 

Tobacco  Poisoning 

1293.  Spastic  Gait 

The  pelvis  is  tilted  to  raise 
the  foot,  which  then 
describes  an  arc  with  the 
toes  scraping  the  ground. 

Disseminated  Sclerosis 

Spastic  Paraplegia 

And  all  spastic  paralysis 
affecting  the  lower 
extremity;     (See  1306) 

1294.  Tottering  Gait 

Atrophy  of  Brain,  Senile 
Bromism 

Cerebellar  Disease 
Hydrocephalus 
Idiopathic    Muscular    Atro- 
phy 
Korsakoff's  Syndrome 
Meningitis 
Mollities  Ossium 
Paralysis  Agitans 

1295.  Reeling  or   Ataxic  Gait 

Short  steps  and  feet  wide 
apart. 

Alcoholism 
Apoplexy   (prsem.) 
Ataxic  Paraplegia 

worse  with  eyes  shut 
Cerebellar  Disease 

the  patient  falls  to  the  side 
opposite  to  the  lesion 

Compression  of  Brain,  I. 
Disseminated  Sclerosis  (x) 
1290-1295 


360 


THE  GAIT 


Reeling  or  Ataxic    Gait — 
continued 
Friedreich's  Disease 

worse  with  eyes  shut 
General  Paralysis  of  Insane 
Hereditary  Cerebellar  Ataxy 

very  rarely  worse  with  eyes 
shut. 

Labyrinthine  Disease 
Locomotor  Ataxy 
Pseudo-tabes 
Sclerosis,  Syphilitic  (x) 
Syringomyelia  (x) 

1296.  Head    Back    and    Feet 
Apart 

Abdominal  Tumours 
Ascites 
Cretinism 
Obesity 
Pregnancy 

Pseudo  -  hypertrophic  Para- 
lysis 

1297.  Waddling  or  Goose  Gait 

Abdominal  Tumours,  Large 

Achondroplasia 

Arthritis,  Multiple 

Ascites 

Coxa  vara,  Double 

Dislocation   of    both    Hips, 

Congenital 

with  head  back 

Ovarian  Cyst 

Pregnancy 

Pseudo-hypertrophic    Para- 
lysis 
on  tip  toe 

Rickets 

Scurvy,  Infantile 


1298.  Foot  Dragged  or  Jerked 

To  detect  malingerers 
examine  the  soles  of  the 
boots  for  difference  of 
wear; 

Hemiplegia 

one  foot  only 

Malingering 

Multiple  Neuritis 

'  foot-drop.'  When  both  feet 
are  affected,  the  gait  is 
'  high  stepping.'     (1299) 

Spasmodic  Spinal  Paralysis 

a  jerky  forward  movement 
of  the  feet 

Spastic  Paralysis 

the  legs  tremble  when  the 
ground  is  touched 

Syphilitic   Spinal   Paralysis 
Tooth's  Paralysis 

1299.  High  Stepping  Gait 

The  feet  are  raised  more 
than  is  usual  to  prevent 
the  toes  scraping  the 
ground; 

Neuritis,  Multiple  _ 
u  the  alcoholic  form 

1300.  Differential 

Chorea 

slow,  even,  shuffling 

Friedreich's  Disease 

reeling  with  feet  apart ; 
the  foot  raised  too  high 
and  brought  down  with 
a  stamp 


Hereditary 
Ataxia 


Cerebellar 


reeling  and   staggering  : — 
movements  in  bed  natural 

1295-1300 


THE  GAIT 


361 


Differential — continued 
Locomotor  Ataxy 

1st  stage,  short  steps  with 
stiff  knees ;  2nd  stage, 
movements  jerky  and 
excessive,  the  foot 
brought  down  with  a 
stamp 

Mercurialism 
running 

Osteitis  Deformans 

shuffling  and  tottering  with 
bent  back  and  drooped 
head 

Paralysis  Agitans 

running  with  shuffling  steps 
and  head  very  forward 
('  festinant  gait ').  Some- 
times the  patient  will 
run  backwards  if  first 
pulled  in  that  direction. 
This  is  termed  '  Eetro- 
pulsion  ' 

Spastic  Paraplegia 

patient  walks  upon  his 
toes  with  feet  turned  in, 
knees  bent,  and  body 
stooping 

Saltatory  Spasm 

jumping 
Thomsen's  Disease 

on  attempting  to  walk,  the 
leg  first  moved  becomes 
stiff  and  remains   so  for 


some  seconds,  then  the 
other  leg  behaves  in  the 
same  way 

(See  Vertigo,  231) 
Scissor  Legs  (see  855) 

1301.  Astasia  Abasia 

The  legs  move  freely  and 
with  good  power  in  bed, 
but  collapse  when  the 
patient  tries  to  stand  or 
walk* 

Disseminated  Sclerosis 
Exophthalmic  Goitre  (x) 
Hysteria 

Locomotor  Ataxy 
Muscular  Wasting 

from  confinement  to  bed 
Peripheral  Neuritis 
Spastic   Paraplegia 

1302.  Schiiller's  Side   Gait   or 

*  Flankengang' 

The  hemiplegic  patient  is 
made  to  move  along  a 
chalked  line  sideways. 
If  he  moves  well  with  the 
healthy  side  advanced, 
but  drags  the  limb  with 
the  affected  side  advanced, 
the  paralysis  is  organic. 
In  hysteria  the  two  legs 
are  moved  equally  badly 
whichever  side  comes  first. 


1300-1302 


362 


ATAXIA 


1303.   ATAXIA 

To  test  ataxia  of  the  upper  extremities  the  patient,  with  the 
eyes  shut,  should  be  told  to  touch  his  nose  or  to  button  up  his 
clothing.  For  the  lower  extremities  he  should  be  required  to 
walk  without  deviations  along  a  straight  line  ;  or,  if  bedridden, 
to  touch  the  dorsum  of  one  foot  with  the  toe  of  the  other.  Muscular 
anaesthesia  involves  some  ataxia. 


Alcoholism 
Ataxic  Paraplegia 
legs — rarely  arms 

Atrophy  of  Brain 

Cerebellar  Tumour 

same     side — more    marked 
in  arm  than  in  leg 

Chorea 

Disseminated    Sclerosis    (x) 
jerky,  bilateral 

Encephalo-myelitis 
Friedreich's  Disease 
first  legs,  then  arms 

General  Paralysis  (x) 
Hemiplegia  (x) 
unilateral 

Hereditary  Cerebellar  Ataxia 
Hydrocephalus 
Hysteria 

Locomotor  Ataxy 
first  legs,  then  arms 

Multiple  Neuritis 
Myelitis,  Chronic 
partial 

Neurasthenia 
Occupation  Neurosis 
Progressive    Muscular  Atro- 
phy 


Syringomyelia 

Tumour  of  Brain 

lesion  of  cerebellum,  pons, 
or  (x)  corpora  quadri- 
gemina 


1304.    Romberg's       Symptom 

(Static  Ataxia) 

The  attempt  to  stand  with 
the  eyes  shut  and  the 
feet  close  together  causes 
pronounced  swaying 
movements.  It  must  be 
ascertained  first  that  the 
patient  stands  without 
swaying  with  the  eyes 
open. 

Anaesthesia  of  Lower  Extre- 
mities 

Ataxic  Paraplegia 

Cerebellar  Disease 
esp.  of  middle  lobe 

Cretinism 

Friedreich's  Disease 
General  Paralysis 
Hereditary         Cerebellar 
Ataxy  (x) 
*Locomotor  Ataxy 
Meniere's  Disease 
Syringomyelia 


1303-1304 


PARALYSIS 


363 


1305.  PARALYSIS 

The  motor  area  in  the  brain  lies  in  front  of  the  Fissure  of 
Rolando,  the  following  being  the  order  of  the  various  centres 
from  above  downwards : — Toes,  Ankle,  Knee,  Hip,  Abdomen, 
Chest,  Elbow,  Wrist,  Fingers,  Thumb,  Neck,  Face,  Lips,  Tongue. 
Anteriorly  to  the  centres  for  the  upper  extremity  are  those 
for  the  head  and  eyes,  and  in  front  of  the  centre  for  the  face  is 
that  for  the  larynx,  while  more  advanced  still,  on  the  same  level, 
is  the  motor  centre  for  speech, 

Paralysis  is  usually  of  the  flaccid  type,  and  may  involve 
muscular  wasting,  R.  D.  and  lost  or  impaired  reflexes.  In 
spastic  paralysis  there  is  neither  muscular  wasting  nor  altered 
electrical  reactions  ;  the  tendon  reflexes  are  exaggerated,  and 
in  paraplegic  cases  both  ankle  clonus  and  the  extensor  plantar 
reflex  are  present.  The  lesions  affecting  spastic  paralysis  he 
in  the  pyramidal  path  between  the  upper  limit  of  the  lumbar 
enlargement  and  the  cortex  of  the  Rolandic  Area. 


1306.  Spasticity 

This  is  found   in    the    fol- 
lowing  diseases  : — 

Amyotrophic   Lateral  Scle- 
rosis 
Ataxic  Paraplegia 
Cerebral  Diplegia 

„        Hemiplegia 
Combined    Degeneration, 

Subacute 
Disseminated  Sclerosis 
Familial  Spastic  Paraplegia 
Fracture    -    Dislocation    of 

Spine 
General  Paralysis  (x) 
Gunshot  and  other  Wounds 


Hsematomyelia 

Hereditary  Cerebellar  Ataxy 

Lathyrism 

Myelitis,  Acute  Transverse 

Pachymeningitis,  Cervical 

Pellagra 

Primary  Lateral  Sclerosis 

Spina  Bifida 

Spinal  Caries 

Syphilitic  Paraplegia 

Syringomyelia 

Tumours      of      Cord 

Meninges 
Tumours  Involving  the  Ver 

tebral  Column 


or 


1305-1306 


364 


PARALYSIS 


1307.  NERVE   PARALYSIS 

In  many  cases  it  is  only  some  of  the  fibres  of  a  nerve  that  are 
affected.  Muscles  subjacent  to  a  serous  inflammation  are  more  or 
less  completely  paralysed  (Stokes'  Law). 


First  Nerve  (Olfactory) 

(See  Anosmia,  588) 

Second  Nerve  (Optic) 
(See  Vision,  544) 

1308.  Third      Nerve      (Motor 
Oculi) 

Usually  due  to  inter- 
peduncular or  crus  lesion. 
It  involves,  when  com- 
plete, dilated  pupil,  exter- 
nal strabismus,  crossed 
diplopia,  paralysed  accom- 
modation and  ptosis. 

Diphtheria 
tj  ciliaris 
Haemorrhage,  Cerebral 
Meningitis,  Basilar 
Moebius'  Disease 
Rheumatism 
Syphilis 

Tobacco  in  Excess 
Tumour,  Cerebral 

„         Orbital 
(See  Strabismus,  495) 

1309.  Fourth    Nerve    (Troch- 
lear) 

Affection    of    C.    quadrige- 
mina,  crus  or  cerebellum. 

It  involves  diplopia,  in 
which  the  false  object 
appears  to  be  below  and 
to  the  outer  side  of  the 
true  one,  and  is  only  ap- 
parent when  the  patient 
looks  down; 


Alcoholism 

Aneurysm,  Cerebral 

Diabetes 

Gout 

Influenza 

Lead-poisoning 

Meningitis,  Basilar 

Rheumatism 

1310.  Fifth  Nerve  (Trigeminal) 

Tumours  in  or  compressing 
the  pons  or  the  nerve 
trunk. 

The  jaw,  when  protruded 
with  the  mouth  open, 
leans  to  the  affected  side. 
The  power  of  mastication 
is  impaired,  the  lacrymal 
and  salivary  secretions 
are  diminished  and,  over 
the  area  supplied  by  it, 
sensation  is  lost. 

Caries 

Cerebral  Haemorrhage 

Meningitis 

Neuritis 

Tumour,  Cerebral 

1311.  Sixth  Nerve  (Abducens) 

Lesion  in  subtentorium — 
pons  or  medulla.  It 
involves  diplopia  (in 
which  the  false  object 
is  external  to  the  true 
one)  and  internal  strabis- 
mus. 

Aneurysm,  Intracranial 
Haemorrhage,  Cerebral 
1307-1311 


PARALYSIS 


365 


Sixth  Nerve — continued 
Mastoiditis,  Acute 
Meningitis 
Otitis  Media 

1  Gradenigo's  Sign  ' 

Syphilis 
Tumour 


1312.  Seventh   Nerve   (Facial) 

To  detect  facial  paralysis, 
the  patient  should  be 
directed  to  close  the  eyes 
and  whistle.  It  is  very 
rarely  present  in  func- 
tional hemiplegia,  and 
when  it  is,  the  platysma 
is  not  involved. 


Central 

Lesion  in  pons  or  below 
nucleus.  In  central  facial 
paralysis  the  patient  is 
unable  to  close  the  eye 
of  the  affected  side  alone, 
though  he  can  close  both 
together  (Revilliod's  Sign). 

Apoplexy 

Cerebro-spinal  Meningitis 

Disseminated  Sclerosis  (x) 

Hysteria 

Infantile  Hemiplegia 

Landouzy-Dejerine  Paralysis 

Locomotor  Ataxy 

Meningitis 

Softening 

Syphilis 

Tetanus 

Tumour 


In  Canal 

Caries,  Temporal 
Haemorrhage 


Otitis  Interna 

,,     Media 
Rheumatism 
Syphilis 
Tubercle  of  Ear 


Superficial 

Acute  Ascending  Paralysis 

Diphtheria 

Injury 

Landouzy-Dejerine  Paralysis 

Neuritis 

Parotitis 

Tumours 


1313.  Nothnagel's  Sign 

Facial  Paralysis,  which  is 
more  marked  as  the 
effect  of  emotions  than  of 
voluntary  movements. 

Tumour  of  O.  Thalamus 


1314.  Eighth  Nerve  (Auditory) 
(See  Hearing,  431  ;   Vertigo, 
231) 


1315.  Ninth     Nerve     (Glosso- 
pharyngeal) 

Taste  is  lost  in  the  posterior 
portion  of  the  tongue  and 
there  is  no  pharyngeal 
reflex. 


1316.  Tenth  Nerve  (Vagus) 

Paralysis  involves  accelera- 
tion of  the  heart,  uni- 
lateral paralysis  of  the 
soft  palate  and  unilateral 
laryngeal  ansesthesia 
(AvehTs  Syndrome). 

1311-1316 


366 


PARALYSIS 


1317.  Eleventh   Nerve   (Spinal 

Accessory) 

Paralysis  interferes  with  the 
shrugging  movement  of 
the  shoulders  and  with 
moving  the  chin  to  the 
opposite  side: 


1318.  Twelfth    Nerve    (Hypo- 
glossal) 

In  paralysis  the  tongue  is 
protruded  to  the  paralysed 
side. 


1319.  Cervical  Sympathetic 

The  pupil  is  contracted, 
the  cilio-spinal  reflex  is 
absent,  and  there  is  slight 
ptosis  and  unilateral  ab- 
sence of  sweating: 


1320,  Phrenic  Nerve 

Unilateral  paralysis  of  dia- 
phragm and  of  the  four 
lower  intercostal  muscles. 


1321.  Intercostal  Nerves 

These  control  the  move- 
ments of  the  eight  upper 
intercostal  muscles. 


1322.  Paralysis   of  Circumflex 

Nerve 

Inability  to  raise  the  arm 
to  a  right  angle. 

Blows  on  Shoulder 
Erb's  Paralysis 
Fibrositis 
Infantile  Paralysis 
Innominate  Aneurysm 
Technic  Paralysis 


1323.  Paralysis    of    Musculo- 
Spiral 

'  Wrist  drop '  or  '  hand  drop.' 
Lead-poisoning 
Leprosy 

Multiple  Neuritis 
Trauma 

1324.  Paralysis     of     Anterior 
Crural 

'  Foot  drop.' 
Landry's  Paralysis 
Multiple  Neuritis 
Myelitis,  Acute 
Peronseal  Nerve,  Paralysis  of 

1325.  Paralysis  of  Sciatic  Nerve 

Loss  of  power  of  flexing  the 
knee  and  of  all  ankle 
muscles. 

1326.  COMPLEX  PARALYSES 

1327.  Paralysis    affecting   De- 
glutition 

Aneurysm  of  Base 
Basilar  Meningitis 
Bulbar  Paralysis 
Diphtheritic  Paralysis 
Disseminated  Sclerosis 
Landry's  Paralysis 
Lesion  of  Medulla 
Myasthenia  Gravis 
Neuritis 

Paralysis  of  Hypoglossal 
Progressive  Muscular  Atro- 
phy 
Pseudo- bulbar  Paralysis 
Tumour  of  Base 

1328.  Paralysis  affecting  Arti- 
culation 

(See   Anarthria,  1239) 

1317-1328 


PARALYSIS 


367 


1329.  Paralysis  of  Soft  Palate 

Basal  Meningitis 
Bulbar  Paralysis 
Caries  of  Spine 
Diphtheria 
Tumours 
Vagus  Paralysis 

Laryngeal  Paralysis  (see  702) 

1330.  Brachial  Monoplegia 

In  spastic  cases  the  lesion 
is  in  the  internal  capsule 
or  some  other  part  of  the 
pyramidal  tract. 

Acute   Ascending   Paralysis 

Amyotrophic   Lateral   Scle- 
rosis 

Axillary  Aneurysm 

Brachial  Plexus 
pressure  upon 

Cancer,  Vertebral 
Caries,  Cervical 
Cervical  Myelitis 
Cervical  Rib 
pressure 

Cord,  Tumour  of 
Diphtheritic   Paralysis 
Disseminated  Sclerosis 
Embolism,  Cerebral 
Encephalitis 
Erb's  Paralysis 
Hsematomyelia 

eighth  cervical  and  first 
dorsal 

Hemiplegia 

Hysteria 

Infantile  Hemiplegia 

Ischsemic  Paralysis 

Klumpke's  Paralysis 

Lead-palsy 

Morvan's  Disease 


Multiple  Neuritis 
Muscular  Dystrophy 
Occupation  Neurosis 
writer's  cramp,  etc. 

Pachymeningitis,  Cervical 
Paralysis  Agitans  (x) 
Poliomyelitis,  Anterior 
Progressive  Muscular  Atro- 
phy 

Serratus  Magnus  Paralysis 
Syringomyelia 
Thrombosis,  Cerebral 
Tooth's  Paralysis,  n. 
Tumour,  Cerebral 

***  The  power  of  the  grasp 
is  the  favourite  method 
of  comparing  the  sound 
with  the  paralysed  side 
in  hemiplegia,  etc. 


1331.  Crural  Monoplegia 

Paralysis  of  one  leg.  The 
centres  for  the  movements 
of  the  lower  extremities 
lie  along  the  margin  of 
the  great  longitudinal 
fissure. 

Abscess,  Cerebral 
Anterior  Poliomyelitis 
Brown-Sequard's  Paralysis 
Cancer,  Vertebral 
Caries,  Vertebral 
Gumma 
Hysteria 

Locomotor  Ataxy 
Meningitis,  Syphilitic 
Myelitis,    Unilateral 
Neuritis 

„       Ant.  Crural 

„       Obturator 
Paralysis  Agitans,  i. 
Pelvic  Tumour 

1329-1331 


368 


PARALYSIS 


Crural    Monoplegia  —  con- 
tinued 
Progressive  Muscular  Atro- 
phy 
Sciatica 

Sclerosis,  Disseminated,  i. 
Syringomyelia 
Tumour,  Cerebral 
,,         of  Cord 

1332.  Diadococinesia 

The  patient  is  made  to 
pronate  and  supinate  the 
forearms  in  rapid  succes- 
sion. If  done  awkwardly 
on  one  side,  there  is — 

Cerebellar  Disease 
of  the  same  side 


1333.  Dysdiadoeocinesia 

Pronation  and  supination 
are  slower  on  affected 
side. 

Tumour  of  Lateral  Lobe 


1334.  Pronation  Sign  (Babin- 

ski's) 

When  the  paralysed  fore- 
arm is  placed  in  supina- 
tion, it  turns  over  to 
pronation. 

Organic  Paralysis 


1331-1334 


HEMIPLEGIA 


369 


1335.   HEMIPLEGIA 

Paralysis  of  one  side.  The  lesion  is  usually  in  the  knee  and 
anterior  two-thirds  of  the  posterior  limb  of  the  internal  capsule  ; 
when,  as  rarely  happens,  it  is  in  the  motor  cortex,  athetosis  is  apt  to 
occur.  Sudden  right  hemiplegia  (hemiplexy),  when  associated  with 
aphasia,  is  usually  embolic. 


1336.  Hemiplegia,  Simple 

Abscess  of  Brain 
incomplete  at  first 

Atrophy  of  one  Lobe 
Birth  Injury 
Brown-Sequard  Paralysis 

same  side 
Caisson  Disease 

a  bubble  in  int.  capsule 
Cerebellar  Tumour 

hemiparesis    of    same    side, 
but  not  involving  face 

♦Cerebral  Haemorrhage 
Cerebro-spinalMeningitis  (x) 
Compression  of  Brain 
Disseminated  Sclerosis  (x) 

♦Embolism   of  Middle   Cere- 
bral Artery 
Haematoma  of  Dura  Mater 
Hemichorea 
incomplete 
Hysteria 
Infantile  Hemiplegia 


Internal  Nodes 

Lesion  of  Crus,  Pons,  Inter- 
nal Capsule,  or  Cortex 

Meningitis  simplex  (x) 

Pachymeningitis  (x) 

Pregnancy  (x) 

Raynaud's  Disease 

Softening  of  Brain 

Syphilitic  Endarteritis 
„  Gumma 

Thrombosis  of  Middle  Cere- 
bral Artery 

Trauma 

Tumour  of  Brain 
gradual 


1337.  Hemiplegia,  Transient 

Embolism,  Cerebral 

General  Paralysis 

Hysteria 

Migraine 

Pregnancy 

Uraemia 


1338.  CROSSED 

1339.  Hemiplegia  with  Oppo- 
site Nueleo-Faeial  Para- 
lysis 

(Millard-Gubler    Syndrome) 
Lesion    of    lower    part    of 
pons.     Sometimes        the 
sixth  nerve  is  involved. 


HEMIPLEGIA 

1340.  Benedikt's  Syndrome 

Tremor  of  one  arm  and  leg 
with  opposite  oculo- 
motor paralysis. 

Lesion  of  Crus  Cerebri 
I  b  1335-1340 


370 


PARALYSIS 


1341.  Hemiplegia  with  Oppo- 
site Third  Nerve  Paraly- 
sis 

Lesion  of  Crus 

1342.  Hemiplegia  with  Oppo- 
site Hypoglossal  Para- 
lysis 

Lesions  involving  spinal 
fibres  of  hypoglossal  and 
one  half  of  upper  part 
of  cord. 

Caries    of    Upper    Cervical 

Vertebrse 
Meningitis 
Syphilis 
Tumours 


1343.  Hemiplegia  with  Oppo- 
site Fifth  Nerve  Para- 
lysis 

Lesion  of  Pons  below  Decus- 
sation. 

1344.  Hemiplegia  with  Motor 
Aphasia 

Lesion  of  third  left  frontal 
convolution. 

1345.  One   Arm  and  Opposite 

Leg 
Infantile  Paralysis 
(See  Parergice,   1396) 


1346.  Paresis  or  Weakness  of 
Legs 

This  may  pass  into  para- 
plegia or  it  may  depend 
simply  upon  general  con- 
ditions. 

Abdominal  Tumours 

Cauda   Equina,  Tumour   of 

Coeliac  Disease 

Congenital  Muscular  Atony 

Cretinism 

Diabetes 

Idiocy 

Idiopathic  Muscular  Atro- 
phy 

Infantile  Scurvy 

Influenza 

Korsakoff's  Syndrome 

Landouzy-Dejerine  Paraly- 
sis 

Lipomatosis  neurotica 

Locomotor  Ataxy 


Myasthenia  Gravis 
Periarteritis  Nodosa 
Polymyositis 

Pseudo -hypertrophic    Para- 
lysis 
Retroversion 
Rickets 

Spastic  Paraplegia,  I. 
Syphilis,  Congenital 
Syphilitic  Spinal  Paralysis 
Syringomyelia 

1347.  Paraplegia 

The  upper  neurone  type  is 
spastic,  the  lower  neurone 
type  flaccid  (1305). 

Acute  Ascending  Paralysis, 
I. 

Amyotrophic  Lateral  Scle- 
rosis 

Aneurysm  of  Abdominal  or 
Descending  Aorta 

Apoplexy,  Spinal 

1341-1347 


PARALYSIS 


371 


Paraplegia — continued 
Ataxic  Paraplegia 

gradual  and  spastic 
Beri-beri 

legs  often  (edematous 
Botulism 
Caisson  Disease 
Caries  of  Spine 
Cerebellar  Abscess 

„  Tumour  (x) 

Cere  bro-  spinal  Meningitis 
Chronic     Atrophic     Spinal 

Paralysis 
Compression  of  Cord,  Slow 
Diphtheritic  Paralysis 

subsequently  affecting  arms 

Dislocation  of  Spine 
Disseminated  Sclerosis 
Dystrophy,    Juvenile    Mus- 
cular 
Fracture  of  Spine 
Friedreich's  Disease,  n. 
General  Paralysis,  in. 
Haematomyelia 
Haemorrhage,  Bilateral  Cere- 
bral 
„     Profuse  General 
Hydrocephalus   (x) 
Hyperaemia,  Spinal 

incomplete 

Hysteria 

Infantile  Paralysis 
Korsakoff's  Syndrome 
Lathyrism 

Locomotor  Ataxy,  ni. 
Malaria 

intermittent 
Malingering 

Meningitis,   Internal  Spinal 
Meningocele 

2  B 


Myelitis,  Acute  or  Chronic 
Neuritis,  Multiple 
Poliomyelitis,  Acute 
Primary  Spastic  Paraplegia 
incomplete 

Pseudo-Hypertrophic  Para- 
lysis, in. 

Purulent  Spinal  Pachymen- 
ingitis 

Reflex  Paraplegia  (x) 
worms,  etc. 

Sclerosis,  Combined 

„         Primary  Lateral 

Softening,  Bilateral  Cerebral 

Spina  bifida  (x) 

Spinal  Meningeal    Haemor- 
rhage 
usually  incomplete 

Syphilitic  Endarteritis 

Syringomyelia 

Thrombosis  of  Spinal  Artery 

Tooth's  Paralysis 

Tumour,  Pelvic 
pressing  on  plexus 

Tumours  in  Spinal  Canal 
The    association    of    para- 
plegia    with     anaesthesia 
usually  negatives  a  cere- 
bral lesion. 

1348.  Diplegia,     or     Bilateral 
Paralysis 

Lesion  of  upper  cervical 
portion  of  spinal  cord. 
Bilateral  cerebral  lesions. 
Lesion  of  c.  callosum, 
of  medulla,  or  of  centre  of 
pons. 

Acute   Ascending   Paralysis 

(Late) 
Amyotonia  Congenita 

arms,  limbs,  trunk,  and 
neck 

2  1347-1348 


372 


PARALYSIS 


Diplegia     or    Bilateral 
Paralysis — continued 

Basilar  Meningitis  (x\ 

Bulbar  Paralysis 

Diphtheria 

Disseminated  Sclerosis,   in. 

Encephalitis 

General  Paralysis  of  Insane 

Haemorrhage,  Cerebral 
into  ventricles 

Hydrocephalus,  Chronic 

Infantile  Diplegia 

Multiple  Neuritis 

Occupation  Neurosis  (x) 
bimanual  occupations 

Periodic  Paralysis 

Pseudo-bulbar  Paralysis 

Spinal  Apoplexy 
,,      Tumours 

Tumours,  Brain 


1349.  Muscular  Hypotonia 

Basilar  Artery,  Thrombosis 
of 

Bulbar  Paralysis 

Cerebellar  Haemorrhage 

General  Paralysis 

Hysteria 

Locomotor  Ataxy 

Muscular  Dystrophies 

Neuritis 

Poliomyelitis,  Acute  An- 
terior 

Pontine  Haemorrhage 

Ventricular  Haemorrhage 

*5i5*  Lower  Neurone  Paralysis  in 
general. 

Paralysis  of  Sphincters 

See   Micturition,  938  ; 
Defcecation,   1084) 


1350.  MOTOR   ANOMALIES 


1351.  Lasegue's  Symptom 

The  patient  can  make  no 
movement  without  look- 
ing to  see  what  he  is 
doing. 

Hysteria 

1352.  Amyosthenia 

A  sudden  temporary  loss 
of  power  in  arm  or  leg. 

Disseminated  Sclerosis 
Hysteria 
Occupation  Neurosis 


1353.  Heterocinesia 

The  patient  does  the 
reverse  of  what  he  is 
told  to  do. 

Hysteria 

1354.  Syncinesia 

If  the  patient  is  told  to 
lift  one  arm,  he  lifts 
both. 

Hysteria 

1355.  Allocinesia 

If  the  patient  is  told  to 
lift  one  arm,  he  lifts  the 
other. 

Hysteria 


1348-1355 


PARALYSIS 


373 


1356.   DIFFERENTIAL 


Amyotrophic  Lateral  Sclerosis 

Spastic  paralysis  of  shoulder 
arm,   and  hand. 

Brown-Sequard's  Paralysis 

Paralysis  and  hyperesthesia 
of  one  side  and  anaes- 
thesia of  the  other  side. 

Bulbar  Paralysis,  Chronic 

Speech  and  swallow.  In  the 
acute  form,  one  or  more 
of  the  extremities  may 
be  affected. 

Disseminated  Sclerosis 

Order  :  one  leg,  the  other 
leg ;  one  arm,  the  other 
arm. 

Erb's  Brachial  Palsy 

Lesion  of  upper  trunk  of 
brachial  plexus.  The 
arm  hangs  by  the  side 
with  the  forearm  pro- 
nated. 

Erb's    'Juvenile'     Dystrophy 

Shoulders,  upper  arms  and 
supinator  longus  (age  15 
to  35). 

Friedreich's  Disease 

Ataxia  and  weakness  first 
in  legs,  but  extending  five 
or  six  years  later  to  arms. 
Big  toes  erect. 

Infantile  Paralysis 

Sudden  :  one  leg,  or  part 
of  one  leg ;  one  arm, 
arm  and  leg,  both  arms 
or  both  legs. 

Klumpke's  Paralysis 

Lesion  of  lower  trunk  of 
brachial  plexus.  Paralysis 


and  wasting  of  flexors 
of  wrist  and  fingers  and 
of  intrinsic  hand-muscles. 

Landouzy-Dej6rine  Paralysis 

Face,  shoulder,  upper  arm, 
and  orbicularis  oculi  et 
oris. 

Landry's  Paralysis 

Successively — legs,  loins, 
abdomen,  thorax,  arms, 
diaphragm,  neck  and 
swallow. 

Myelitis  Acute  (cervical) 
Both  arms. 

Periodic  Paralysis 

Legs,  or  legs  and  arms ; 
rarely  neck,  tongue,  and 
pharynx. 

Progressive  Muscular  Atrophy 

Hand  first,  then  shoulder 
and  trunk — not  spastic. 

Pseudo-hypertrophic   Paralysis 

Legs  —  calf  and  glutei 
muscles  large. 

Syringomyelia  (Paresis) 

One  hand,  triceps,  shoulder. 

Tooth's  Paralysis 

Inability  to  dorsiflex  great 
toe.  Later,  paralysis  ex- 
tends slowly  up  the  legs 
and  arms. 

Volkmann's    Ischsemic    Para- 
lysis 

Due  to  pressure  of  splints  or 
bandages.  All  flexor  ten- 
dons of  wrist  and  fingers 
rigidly  contracted  and 
the  muscles  wasted. 

1356 


374  SPINAL  CORD 


1357.    THE    SPINAL    CORD 

In  early  foetal  life  the  cord  is  of  the  same  length  as  the  vertebral 
column,  but  the  latter  outgrows  it  so  rapidly  that  at  birth  it  reaches 
only  to  the  third  lumbar  vertebra,  while  in  adults  it  stops  at  the 
lower  border  of  the  first.  In  consequence  of  this  disparity,  the 
spinal  nerves  emerge  from  the  canal  at  a  point  below  the  junction 
of  the  roots  with  the  cord.  From  the  twelfth  dorsal  to  the  third 
cervical  nerve  the  difference  between  the  two  points  is  represented 
by  the  body  of  one  vertebra. 

The  cord  is  divided  theoretically  into  segments  named  after  the 
corresponding  spinal  nerve-roots.  The  Cervical  Enlargement  at 
its  greatest  circumference  lies  opposite  the  fifth  cervical  vertebra  ; 
it  is  the  lower  neuron  centre  for  the  muscles  of  the  neck,  shoulder- 
blade,  arms,  and  hands,  the  diaphragm  belonging  chiefly  to  the 
fourth  cervical  segment.  The  Lumbar  Enlargement  at  its  greatest 
circumference  is  opposite  the  twelfth  dorsal  vertebra.  It  is  the 
lower  neuron  centre  for  the  muscles  of  the  pelvis,  thigh,  and  leg. 
The  centres  for  the  rectum  and  bladder  are  in  the  third  and  fourth 
sacral  segments,  and  that  for  the  sphincter  ani  in  the  fifth.  Some 
investigators,  however,  believe  these  centres  to  be  in  the  sym- 
pathetic system. 


1357 


Front    Back 
view     view 

Fig.  10. — Segmental  Areas  of  the  Cord.    (Adapted  from  Tooth.) 
Front  and  back  view  conjoined  in  one  figure. 


376 


REFLEXES 


Sc&puLar.. 


Elbow  Jerk. 


Epigastric, 


Abdominal,. 


Cremasteric 
GLutde&l. 

* 

PL&ntar.  / 


•\  Cord  ends. 
\  Knee  Jerk. 


7  AnkLe  CLonus. 


Fig.  11. — Localisation  of  Reflexes 


REFLEXES 


377 


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378  REFLEXES 

1358.  REFLEXES 

These  are  divided  into  Superficial  or  Cutaneous  and  Deep  or 
Tendinous.  They  are  lessened  or  exaggerated  according  to  the 
position  of  the  lesion  and  whether  this  lesion  is  destructive  or 
irritant.  Now  the  upper  neuron  has  normally  an  inhibiting  effect 
upon  the  muscles  which  derive  their  activity  from  the  lower  neuron. 
The  action  may  be  compared  to  that  of  the  governor  of  a  steam 
engine ;  if  this  is  detached  the  engine  will  '  race,'  and  similarly, 
a  destructive  lesion  in  the  upper  neuron  will  result  in  exaggerated 
reflexes,  and  the  same  effect  will  ensue  when  a  lesion  of  the  lower 
neuron  is  stimulative. 

The  reflex  arc  comprises  the  afferent  nerve,  the  anterior  horn 
of  the  cord,  the  efferent  nerve,  and  the  muscle.  When  the  function 
of  any  of  these  is  lost,  the  chain  is  broken  and  the  attempt  to  elicit 
the  reflex  will  fail.  Thus,  if  the  skin  is  anaesthetic,  the  anterior 
cornu  or  the  motor  nerve  the  seat  of  a  destructive  lesion,  or  the 
muscle  wasted  till  the  sarcous  elements  have  vanished,  the  reflex 
will  fail. 

When  endeavouring  to  elicit  a  reflex  the  patient  should  be  made 
to  close  his  eyes.  The  first  few  attempts  are  the  most  important, 
as  the  response  may  fail  from  fatigue.  In  the  case  of  the  tendon 
reflexes,  the  muscles  must  be  relaxed  to  start  with.  The  knee-jerk 
is  the  most  important.  For  this  the  patient  should  sit  with  one 
leg  crossed  over  the  other  and  hanging  loose ;  the  examiner  then 
strikes  the  ligamentum  patellae  with  the  ulnar  side  of  his  hand  or 
with  an  instrument  specially  made.  If  the  patient  is  confined  to 
bed,  the  nurse  should  raise  and  support  the  weight  of  the  thigh 
without  the  patient's  co-operation.  When,  owing  perhaps  to 
short  and  fat  thighs,  the  jerk  is  difficult  to  elicit,  reinforcement 
will  help.  Jendrassik's  consists  in  making  the  patient  interlace 
the  fingers  of  the  two  hands  and  try  hard,  but  vainly,  to  separate 
them;  while  Kronig's  Reinforcement  is  obtained  by  making  the 
patient  look  at  the  ceiling  and  draw  a  deep  breath.  If  the  quadriceps 
femoris  muscle  can  be  felt  to  contract,  it  is  tantamount  to  a  knee 
jerk.  Both  superficial  and  deep  reflexes  are  normal  in  the  primary 
muscular  dystrophies  except  for  the  muscular  weakening. 

1358 


RE  FLEXES 


379 


1359.  CUTANEOUS   REFLEXES 

Most  of  these  are  found  only  in  a  certain  proportion  of  normal 
subjects. 


1360.  Cutaneous     Reflex     In- 
creased 

Amyotrophic   Lateral    Scle- 
rosis 
Angular  Curvature 
Ataxic  Paraplegia 
Dysrnenorrhoea 
Infantile  Hemiplegia 
Leptomeningitis,  Spinal 
Locomotor  Ataxy,  i.  (x) 
Meningitis,  Spinal 
Myelitis 
Neurasthenia 
Pachymeningitis 
Primary  Spastic  Paraplegia 
Rheumatoid  Arthritis 

esp.  the  cremasteric 
Sciatica 

cremasteric 

Spastic  Cerebral  Paraplegia 

Strychnine  -  poisoning 

Tetanus 

Tetany 

Wasting  Diseases 

1361.  Cutaneous  Reflex  Dimin- 
ished or  Lost 

Acute  Ascending    Paralysis 
Amyotonia  Congenita 
Anaesthesia,  Peripheral 
Apoplexy,  Severe 
„  Spinal 

Asphyxia 
Catalepsy,  Severe 
Cholera,  ii. 
Chorea 


Coma 

Disseminated  Sclerosis 

epigastric  reflex 
Enteric  Fever 
Friedreich's  Disease 
Hemiplegia 

healthy  side 
Hysteria 

plantar  only 

Infantile  Paralysis 
Locomotor  Ataxy,  n. 
Myelitis 

Narcotic-poisoning 
Neuritis,  Multiple 
Peripheral  Paralysis 
Peritonitis 

Poliomyelitis,  Anterior 
Progressive  Muscular  Atro- 
phy 

Spastic   Paraplegia  (x) 

Spinal  Hyperemia 
,,       Paralysis,  Acute 
„  „  Chronic 

Atrophic 

Tumours  of  Cord 

1362.  Epigastric  Reflex 

On  stroking  the  epigastrium 
horizontally,  the  abdo- 
minal muscles  contract 
(62  per  cent.). 

1363.  Abdominal  Reflex 

When  the  abdomen  is 
stroked  longitudinally, 
the  abdominal  muscles 
contract  (99  per  cent.). 

1359-1363 


380 


REFLEXES 


1364.  Rosenbach's  Sign 

The  absence  of  a  reflex  on 
pinching  the  skin  of  the 
abdomen  on  the  paralysed 
side. 

Hemiplegia 
Peritonitis,  Acute 
both  sides 

1365.  Hypogastric     Reflex    of 

Bechterew 

When  the  skin  of  the 
internal  surface  of  the 
thigh  is  stroked,  con- 
tractions of  the  lower 
abdominal  muscles  follow. 
The  reflex  is  said  to 
correspond  to  the  lower 
dorsal  portion  of  the 
cord. 

1366.  Cremasteric  Reflex 

On  titillation  of  the  inner 
side  of  the  thigh,  the 
cremaster  contracts  and 
draws  up  the  testicle 
(66  per  cent.). 

1367.  Dartos  Reflex 

The  patient  stands  with 
his  feet  wide  apart  while 
the  surgeon  suddenly 
applies  cold  to  the  peri- 
nseum.  The  non-striated 
fibres  of  the  dartos  muscle 
undergo  vermicular  con- 
traction. 


1368.  Bulbo-Cavernous   Reflex 

The  glans  is  pinched  or 
pricked  while  the  finger 
presses  through  the  scro- 
tum upon  the  bulb  of 
the  urethra  —  a  brisk 
twitch  is  felt. 

Absent  in  Locomotor  Ataxy 


1369.  Inguinal      or      GeigePs 
Reflex 

This  is  a  substitute  for 
the  cremasteric  reflex  in 
the  case  of  females,  the 
muscular  fibres  at  the 
upper  edge  of  Poupart's 
Ligament  contracting  on 
titillation  of  the  thigh. 

1370.  Interscapular  Reflex 

This  consists  in  adduction 
of  the  shoulder  blade  when 
its  inner  edge  is  stroked 
(15  per  cent.). 

1371.  Glutaeal  Reflex 

The  glutseal  muscles  con- 
tract when  the  skin  over 
them  is  irritated  (28  per 
cent.). 

1372.  Plantar  Reflex 

Titillation  of  the  sole  is 
followed  by  flexion  of  the 
toes  (98  per  cent.). 

PLANTAR  EXTENSION 
REFLEXES 

1373.  Babinski's  Reflex 

Extension  instead  of  flexion 
of  the  great  toe  on  titilla- 
tion of  the  outer  side  of 
the  sole,  the  patient 
lying  on  his  side  with 
the  knees  semi-flexed.  It 
always  indicates  some 
affection  of  the  pyra- 
midal system,  and  its 
presence  in  conscious 
adults  excludes  neuras- 
thenia and  hysteria. 
But  it  is  the  normal 
condition  in  the  new-born 
and  is  common  up  to  three 
years  of  age.  It  may 
be  frequently  elicited  in 
healthy    subjects    during 

1364-1373 


REFLEXES 


381 


Babinski's 
tinned 


Reflex  —  con- 


sleep     and     in  alcohol, 

chloroform,  morphia, 

hyoscine,      or  epileptic 
stupor. 

Amaurotic  Family  Idiocy 
Amyotrophic   Lateral    Scle- 
rosis 
Apoplexy 

early 

Ataxic  Paraplegia 

Disseminated  Sclerosis 

Friedreich's  Disease 

Hydrocephalus  (x) 
*Lesions  of  Pyramidal  Tract 

Locomotor  Ataxy 
•  Meningitis  (x) 

Myelitis,  Transverse 

Spastic  Paraplegia 

Syringomyelia 

Tumour,  Cerebellar 
„        Spinal 

Uraemia  (x) 

1374.  Schafer's  Reflex 

On  pinching  the  skin  over 
the  tendo  Achillis,  the 
great  toe  is  dorsi-flexed. 

Organic  Nervous  Affections 


1375.  Gordon's 
Reflex 


Paradoxical 


When  pressure  is  made 
through  the  relaxed  calf 
muscles  upon  the  deep 
flexor  muscles  beneath, 
the  great  toe  is  dorsi- 
flexed. 

Lesion  of  Pyramidal  Tract 
especially  when  irritative 


1376.  Oppenheim's  Reflex 

When  the  inner  side  of  the 
leg  is  either  pinched  or 
deeply  stroked  from  above 
downwards  —  or  both, 
dorsi-flexion  of  the  foot 
and  toes  follows. 

Lesion  of  Pyramidal  Tract 
Post-Epileptic  Stupor 

1377.  Rossolimo's  Reflex 

When  the  plantar  surface 
of  the  great  toe  is  stroked, 
extension  or  abduction 
of  the  toe  occurs. 

Lesion  of  Pyramidal  Tract 

1377a.  Bechterew's    Extensor 
Reflex 

Percussion  of  cuboid  bone 
is  followed  by  dorsi- 
flexion  of  the  toes. 

Spastic  Paralysis 


1378.  Hirschberg's  Reflex 

Adduction  of  the  foot  on 
slight  titillation  of  the 
base  of  the  great  toe. 

Organic  Disease 

1379.  Brissaud's  Reflex 

A  contraction  of  the  tensor 
fascise  femoris  on  titilla- 
tion of  the  sole.  It  is 
sometimes  present  when 
the  toes  fail  to  move. 

As  Babinski's  Plantar  Reflex 

1380.  Palatine  Reflex  Lost 

On  touching  the  mucous 
membrane,  there  is  no 
elevation  of  the  soft 
palate. 

*Hysteria 

1373-1380 


382 


REFLEXES 


1381.  TENDON  OR  DEEP  REFLEXES 


1382.  Knee-Jerk  Lost  or  Less- 
ened 

(Westphal's  Sign) 

Acute  Ascending  Paralysis 

Adiposis  dolorosa 

Amyotonia  Congenita 

Anterior  Crural  Paralysis 

Apoplexy 
transient 

Beri-beri 

Cerebro-  spinal    Meningitis 

Chorea  (x) 

Coma 

Diabetes,  II. 

Diphtheria 

even  without  paralysis 

Dislocation  of  Spine 

Epilepsy 
transient 

Ergotism,  Chronic 

Fracture  of  Spine 

Friedreich's  Disease 

General  Paralysis  of  Insane 
S.  unilateral 

Hsematomyelia,  I. 

Hereditary  Muscular  Atro- 
phy 

Hydrocephalus 

Idiopathic  Muscular  Atrophy 

Infantile  Paralysis 

if    quadriceps    extensor    is 
affected 

*Locomotor  Ataxy 
Leprosy 

Leptomeningitis,  Spinal,  n. 
Multiple  Neuritis 

if  anterior  crural   nerve   is 
involved 

Myasthenia  Gravis 

after  several  taps 


Myelitis,  Descending 
„         Transverse 
Paralysis   Agitans   (x) 
Periodic  Paralysis 
Pernicious  Anaemia  (x) 
Progressive  Muscular  Atro- 
phy 
if  quadriceps  is  involved 

Pneumonia,  Acute 

in  children — 7th  to  8th  day 

Pseudo-hypertrophic    Para- 
lysis (very  late) 

Sciatica  (x) 

Shock 
transient 

Spinal  Hsemorrhage 
„       Meningitis 

Syringomyelia,  in. 

Tooth's  Paralysis 

only  when  quadriceps  is 
affected 

Tuberculous  Meningitis,  in. 

Transverse  Softening  of  Cord 

Tumour,  Subtentorial 

reflex  variable 
***  It  occurs  so  rarely  in 
hysteria  as  to  be  a 
curiosity  ;  but  is  common 
in  wasted  infants  with- 
out any  affection  of  the 
nervous  system. 

1383.  Knee-Jerk  Exaggerated 

Exaggeration  of  the  knee- 
jerk  implies  either  that 
the  inhibiting  cerebral 
fibres  are  impaired  or 
that  the  irritability  of  the 
spinal  centre  is  increased. 
The  reflex  arc  remains 
intact.  It  occurs  in  all 
serious  disorders  to  some 
extent.     When  organic  it 

1381-1383 


REFLEXES 


383 


Knee -Jerk    Exaggerated — 
continued 
is    associated    with    the 
signs  of  spastic  paralysis 
(1305). 

Amyotrophic   Lateral  Scle- 
rosis 

Apoplexy 

Arthritis,  Chronic 

Ataxic  Paraplegia 

Brown-Sequard's  Paralysis 

Cancer  of  Stomach 

Compression  of  Cord,  Slow 

Convalescence  from  Fevers 

Disseminated  Sclerosis 

Dysmenorrhcea 
at  period 

Embolism  of  Brain 

Erb's  Spinal  Paralysis 

General  Paralysis  (x) 

Hemiplegia 

esp.  on  paralysed  side 

Hereditary  Cerebellar  Ataxy 

Hydrophobia 

Hysteria 

Infantile  Hemiplegia 

Leptomeningitis,   Spinal,   I. 

Morvan's  Disease 

Myelitis,  Chronic 

Neurasthenia 

Pyramidal  Tract  Lesions 

Rheumatoid  Arthritis 

Spasmodic  Spinal  Paralysis 

Spinal  Meningitis,  Chr.,  i. 

Strychnine -poisoning 

Syphilitic  Spinal  Paralysis 

Syringomyelia 

Tetanus 

Tetany 

Tuberculosis,  Pulmonary 

Tumour  of  Brain 
of  Cord 


Ulcer  of  Stomach 

Uraemia  (pramion.) 

Malingerers  sometimes  wil- 
fully exaggerate  the  knee 
jerk.  To  expose  them  the 
patella,  and  not  its  liga- 
ment, should  be  tapped. 
As  no  jerk  should  ensue, 
the  presence  of  one  must 
be  intentional. 

1384.  MacCormac's  Reflex 

'  Crossed    Adductor     Jerk.' 

A  variety  of  exaggerated 

knee-jerk. 
On      striking     one     patella 

tendon,   the   opposite  leg 

is  adducted. 

1385.  Adductor  Jerk 

The  thigh  should  be  ab- 
ducted and  the  tendon 
of  the  adductor  magnus 
tapped.  Contraction  of 
the  adductors  results 

As  knee-jerk 

1386.  Tendo-Aehillis  Jerk 

As  knee-jerk,  but  earlier. 
In  locomotor  ataxy  and 
peripheral  neuritis  this 
reflex  may  be  found  when 
that  of  the  knee  is  absent. 
The  patient  should  kneel 
on  a  chair  with  the  feet 
projecting  over  the  edge. 

1387.  Mendel's  Instep  Reflex 

The  foot  being  placed  with 
its  inner  surface  on  a 
firm  basis,  the  dorsal 
tendons  are  percussed. 
Dorsiflexion   follows. 

Functional  Affections 

Locomotor  Ataxy 

Absent  or  difficult  to  elicit 
in  other  organic  diseases. 

1383-1387 


384 


REFLEXES 


1388.  Patellar  Clonus 

The  observer,  with  the 
root  of  the  hand  resting 
on  the  thigh  of  the 
recumbent  patient,  holds 
the  patella  between  the 
tips  of  his  finger  and 
thumb  and  suddenly 
pushes  it  downwards. 
Clonus  continues  as  long 
as  the  pressure  is  main- 
tained in  well  -  marked 
cases  of 

Exaggerated     Knee -Jerk 
(See  1383) 


1389.  Chorea     Knee     Pheno- 
menon 

On  tapping  the  ligamentum 
patellse  the  leg  remains 
fully  extended  for  a 
second  or  two,  the  foot 
and  toes  jerking. 

1390.  Ankle-Clonus 

With  the  patient's  knee 
slightly  bent,  sudden,  firm 
and  continued  pressure 
is  made  upwards  upon 
the  ball  of  the  foot.  The 
result  is  a  series  of  clonic 
contractions  at  the  ankle 
joint  so  long  as  the 
pressure  is  maintained. 
(Contractions  6  to  9  per 
second.)  In  general, 
ankle-clonus  is  present 
where  the  knee-jerk  is 
exaggerated  from  organic 
causes  (1383).  It  is  most 
marked  in  disseminated 
sclerosis.  In  malingerers 
the  rhythm  is  irregular, 
provided  they  are  made 
to  do  something  else 
simultaneously. 


1391.  Scapulo-Humeral  Reflex 

When  the  spinal  border 
of  the  scapula  is  struck 
just  above  the  inferior 
angle,  there  is  external 
rotation  of  the  arm. 

Exaggerated  by  lesions  above 
cervical  enlargement. 

1392.  Triceps  Tendon  Jerk 

The  upper  arm  should  be 
supported  horizontally 
with  the  forearm  loosely 
flexed  at  a  right  angle.  On 
the  tendon  being  tapped 
the  forearm  is  extended. 

As  knee-jerk,  but  connected 
with  8th  cervical  and 
1st  dorsal  segments. 

1393.  Supinator  Jerk 

The  hand  being  prone,  tap 
the  tendon  of  the  supi- 
nator longus  just  above 
the  styloid  process  of  the 
radius.  Supination  of  the 
hand  will  follow  (5th 
cervical   segment). 

1394.  Wrist-Jerk 

The  hand  should  be  pro- 
nated  and  flexed  while 
the  dorsum  of  the  wrist 
is  tapped.  Often  absent 
in  health. 

1395.  Jaw-Jerk 

The  jaw  should  be  open. 
When  the  chin  is  tapped 
the  mouth  will  shut. 
The  two  sides  should 
be  tested  separately. 
Pseudo-bulbar  paralysis 
may  give  a  clonus. 

Lesion  of  Motor  Nucleus  of 
Fifth  Nerve 

It  is  common  in  Amyo- 
trophic Lateral  Sclerosis. 

1388-1395 


PARERGLE 


385 


1396.  PARERGI^E 

The  following  phenomena  are  generally  classed  as  reflexes  ; 
but  the  two  differ  very  essentially.  A  term  implying  collateral 
action   is  preferable  and  the  writer  suggests  Parergia  (irdpa  epyov). 


1397.  Hoover's  Sign 

On  attempting  to  raise  the 
paralysed  limb,  the  oppo- 
site heel  is  pressed  into 
the  mattress. 

Organic  Hemiplegia 


1398.  Babinski's  Fan  Sign 

The  patient  lying  on  his 
back  with  the  arms  folded 
is  made  alternately  to  flex 
and  extend  the  trunk  on 
the  thigh.  The  toes 
gradually  separate  from 
each  other  in 

Lesion    of    the    Pyramidal 

Tract 
Hysterical  Paralysis 

8  per  cent,  of  cases 

1399.  Babinski's    Hip    Pheno- 
menon 

The  patient  lying  supine 
upon  the  bed,  with  the 
legs  uncovered,  is  directed 
to  sit  up  suddenly.  In 
health,  both  thighs  and 
legs  would  be  slightly 
flexed.  If  the  paralysed 
thigh  moves  the  most, 
it  indicates  Organic 
Disease ;  if  the  sound 
thigh  alone  moves,  Func- 
tional Disease. 

Conversely  if  a  patient  sit- 
ting on  the  floor  with 
folded  arms  tries  to  lie 
down,  the  affected  foot 
rises  in  Organic  Hemi- 
plegia. 

2i 


1400.  Bechterew's    Deep 
'  Reflex  * 

A  flexion  movement  of 
the  hip  and  knee  follows 
dorsiflexion  of  the  foot 
and  toes,  the  foot  and 
toes  having  been  first 
plantar-flexed  by  the 
hand  of  the  surgeon. 

Intracranial  Lesion  of  Motor 

Tracts 
Myelitis 
Spinal  Syphilis 
Traumatic  Lesion  of  Spine 

1401.  Brudzenski's  Neck  Sign 
When  the  head  is  flexed  on 

the    chest,    the    hip    and 
knee  are  also  flexed. 

Meningitis 

1402.  Brudzenski's  Leg  Sign 
When    one   lower    limb     is 

passively  flexed  on  the 
abdomen  to  its  full  extent 
the  patient  draws  up 
the  other  to  a  similar 
extent. 

Meningitis 

1403.  Grasset-GraussePs   Phe- 
nomenon 

The  patient  lying  on  his 
back  can  raise  either  limb 
separately,  but  not  both 
together. 

Hemiplegia,  Organic 
c  1396-1403 


386 


PARERGI7R 


1404.  Paradoxical  Contraction 

Tonic  contraction  of 
anterior  tibials  upon  tho 
physician  suddenly  flex- 
ing the  foot  on  the  leg. 

Excessive  Spasticity  of  Legs 


1405.    Striimrel's    Tibialis 
Phenomenon 

The  attempt  to  draw  up 
the  paralysed  leg  causes 
involuntary  dorsiflexion 
of  the  ankle. 

Organic  Hemiplegia 


1404  1405 


SPASM  AND  RIGIDITY 


387 


1406.  SPASM    AND    RIGIDITY 


CLONIC  SPASMS 


1407.  Tremor,  Subsultus,   and 
Twitchings 

Tremor  in  the  hand  is 
best  seen  when  the  arm 
is  held  out.  In  malin- 
gerers, it  generally  ceases 
when  their  attention  is 
directed  to  something 
else.  The  surgeon  should 
pretend  to  be  examining 
the  veins. 

Fibrillary  tremor  implies 
exhausted  muscles. 

Abscess  of  Brain 
Absinthism  (x) 

upper  extremities  only 

*  Alcoholism,  Chronic 

fine 

Amyotrophic    Lateral   Scle- 
rosis 

Anaemia  of  Brain 

Apoplexy 

Ataxic  Paraplegia 
face 

Aura  epileptica 
Bell's  Mania 

*  Chorea  Minor 

Chorea  Senilis 

movements     cease     during 
sleep 

Cocainism 

Compression  of  Brain 
Congestion  of  Brain 
Delirium  Tremens 
Disseminated  Sclerosis 
Emotions 
Encephalitis 


2  c  2 


Enteric  Fever 

third  week 
Epilepsy,  n. 
Exophthalmic  Goitre 

fine,  rapid 
Fatigue 

Friedreich's  Disease 
General  Paralysis 
begins  in  hands,  but  spreads 
to  lips  and  tongue.  Also 
angles  of  mouth  and  of 
eyes  ;  the  last  is  an  earlv 
symptom  —  Crichton- 
Browne's  sign. 

Haematoma,  Dural 

Hemiplegia,  Post 

Hereditary  Cerebellar  Ataxy 

Hydrocephalus,    Spurious 

Hyperpyrexia  (297) 

Hysteria 

rapid,  S.  unilateral 

Idiopathic   Muscular  Atro- 
phy 

Intermittent  Claudication 
myokymia  of  calf  muscles 

Intestinal  Irritation 

Jaundice 

Korsakoff's  Syndrome 

Lead-poisoning 

Mercurial-poisoning 

Meningitis 

Mimic  Tic 

Morphinomania 

Myelitis 

Myokymia   (1408) 

Neurasthenia 
rapid 

1406-1407 


388 


SPASM  AND  RIGIDITY 


Tremor,      Subsultus,      and 
T  witchings — continued 
Neuritis,  I. 
local 

Neuroma 

Occupation  Neurosis 
Paralysis  Agitans 

'  cigarette  -  rolling  '  move- 
ment of  fingers — ceasing 
on  voluntary  movement. 
Head  unaffected  during 
sleep. 

Paralysis,  Bulbar,  I. 
Petit  Mai 

Poliomyelitis,  Chr.  Ant. 
Progressive  Muscular  Atro- 
phy 
fibrillary 

Prostration 
Rheumatism,  Acute 
Rheumatoid  Arthritis 
Roundworms 
*Senility 
slow 
Sleeping  Sickness,  n. 
Spastic  Spinal  Paralysis 
Spinal  Apoplexy,  I. 
„      Concussion 
„      Meningitis,  Int. 
„      Paralysis,       Chronic 
Atrophic 
Strychnine 

idiosyncrasy  or  over-dose 

Syringomyelia 

Tooth's  Paralysis  (x) 

Tumour  of  Brain 

esp.  of  cerebellum,  pons, 
c.  quadrigemina  or  frontal 
lobe ;    often  unilateral 

Tumour  of  Cord 
Typhic  State  (62) 


Uraemia 
Werdnig-Hofmann  Atrophy 

Tremor  occurs  in  health 
after  unaccustomed  exer- 
cise and  after  abuse  of 
tea  or  tobacco. 

Tremors  are  practically 
absent  in  all  the  primary 
muscular  dystrophies. 

(See  Facial  Twitching,  405) 

1408.  Myokymia 

Fine  twitching  of  a  sub- 
cutaneous muscle  and 
notably  of  the  orbicularis 
oculi  where  it  is  known 
popularly  as  '  live  blood.' 
It  implies  bodily  fatigue 
or  degenerating  muscle. 

1409.  Quinquaud's  Sign 

This  consists  in  the  '  little 
shocks  '  elicited  when  the 
surgeon's  palm  is  pressed 
by  the  tip  of  the  patient's 
forefinger.  It  can  be  felt 
when  the  usual  tremor 
is  absent. 

Chronic  Alcoholism 
Locomotor  Ataxy 

1410.  Intention  Tremor 

Tremor  on  voluntary  move- 
ment. It  ceases  during 
repose,  is  very  slight  at 
the  beginning  of  a  volun- 
tary movement,  and 
gradually  increases  in 
force  and  rapidity.  Test 
this  by  asking  the  patient 
to  raise  a  glass  to  his  lips. 

Alcoholism,  Chronic 
Cerebellar  Tumour 
*Disseminated  Sclerosis 
Diplegia,  Congenital 
Exophthalmic  Goitre 

1407-1410 


SPASM  AND  RIGIDITY 


389 


Intention  \TsEMOBr-continued 

Hereditary  Cerebellar  Ataxy- 
Hysteria 

Infantile  Hemiplegia 
Mercurialism 

upper  limbs  first 
Neurasthenia  (x) 
Occupation  Neurosis  (x) 
Plumbism 
Tumour    of    opposite    opt. 

thalamus  and  c.  quad. 


1411.  Jactitation  and  Jerking 

Choreiform  contractions  are 
best  seen  when  the  hands 
are  placed  above  the  head. 

Aorta,  Arterio-sclerosis  of 

arm 

Cerebral  Diplegia 

Cerebro -spinal  Meningitis 

Chorea,  Dubini's  Electric 

one  arm  or  one  leg  first, 
then  the  same  on  the  op- 
posite side 

Chorea,  Henoch's  Electric 

neck  and  shoulder  chiefly 
affected 

Chorea,  Huntington's 

the  movements  can  be 
arrested  by  a  strong  effort 
of  the  will.  They  cease 
during  sleep. 

*  Chorea,  Major  and  Minor 

cease  during  sleep 
Chorea,  Post-hemiplegic 
Chorea,  Rhythmic 

localised 
Chorea,  Senile 
Compression  of  Cord,  Slow 
Concussion  of  Spine 


Gillcs      de      la     Tourette's 

Disease 
Habit  Spasm 
Haemorrhage,  Extensive 
Hereditary  Cerebellar  Ataxy 
Hysteria 

Infantile  Hemiplegia 
Intermittent  Limp 
Locomotor  Ataxy 
Morvan's  Disease 
Occupation  Neurosis 
Paralysis  of  Infants,  Spastic 
Paramyoclonus  Multiplex 

rapid — 50  to  150  per  minute 

Pericarditis,  Severe 
Sclerosis,  Cortical 
Sequela  of  Fractured  Limb 
Strychnine  Poisoning 
Syringomyelia 
*Tetanus 
Tic  Convulsif 
Typhic  State  (62) 

1412.  Saltatory  Spasm 

Jumping  movements  pro- 
duced by  violent  con- 
traction of  the  muscles 
of  the  lower  extremity. 

Hysteria 

1413.  Salaam  Spasm 

A  bowing  movement  pro- 
duced by  clonic  con- 
tractions of  the  trunk 
muscles. 

Dentition 
Epilepsy 

Meniere's  Disease 
Rickets 
Spasmus  nutans 

(See  Oscillation,  362) 

1410-1413 


390 


SPASM  AND  RIGIDITY 


1414.  Convulsions 

The  loss  of  consciousness 
(with  few  exceptions) 
distinguishes  convulsions 
from  rigors. 

Abscess  of  Brain  (x) 

Absinthism 

Acute  Yellow  Atrophy 

Addison's  Disease 

Ague 

cold  stage  in  children 
Alcoholism,  Chronic 
Anaemia  of  Brain 
Aortic  Stenosis 
Apoplexy,  Cortical 

unilateral 
Asphyxia  (term.) 
Cerebro- spinal  Meningitis 
Cirrhosis  of  Kidney 
Coal-gas-poisoning 
Compression  of  Brain 
Cysticerci  of  Brain 
^Dentition 
Disseminated  Sclerosis  in. 

often  unilateral 
Encephalitis 
Enteritis,  Acute 

in  children 

Epilepsy 

Ergotism,  Spasmodic 

Exanthemata 

onset ;  in  children  this 
represents  the  rigor  of 
adults 

Exostosis  of  Skull 

Frights 

General  Paralysis  of  Insane 

Hematoma,  Dural 

recurrent 

Haemorrhage 

Heart  Disease,  Congenital 


Hydrocephalus,  Chronic 
,,  Spurious 

Hydronephrosis 
Hydrophobia 

tetanoid 
Hyper semia  of  Brain 
Hyperpyrexia  (297) 
Hypertrophy  of  Brain 
Hysteria 
Idiocy 
Indigestion 
Infantile  Hemiplegia 

onset 
Infantile  Paralysis 

onset 

Intussusception 
Irritating  Scar 
Jacksonian  Epilepsy 

muscular  area  limited, 
consciousness  usually 

retained.  The  muscles 
involved  supply  the  key 
to  the  position  of  the 
lesion. 

Jaundice  (x) 
Lead-poisoning,  Chronic 
Meningitis 
Myelitis,  Acute 
Myoclonus  Epilepticus 
Nephritis,  Acute,  in. 
Pachymeningitis,   Cerebral 
Pneumonia,  Acute 
in  children 

Poisoning  bj^ — 

arsenic,  alcohol,  brucia, 
hydrocyanic  acid,  picro- 
toxine,  strychnine,  to- 
bacco, and  narcotico- 
irritants  in  general.  In 
children  they  occur  after 
an  overdose  of  atropin, 
morphin,  or  santonin. 

1414 


SPASM  AND  RIGIDITY 


391 


Convulsions — continued 

Pontine  Haemorrhage 

Pregnancy 

Puerperal  state 

Rickets 

Roundworms    and    Tape- 
worms 

Salvarsan-poisoning 

Softening  of  Brain 

Spina  bifida 

when  about  to  burst 

Spinal    Meningeal    Haemor- 
rhage 

Starvation 

Status  Lymphaticus 

Stokes-Adams'  Disease 

Sunstroke 

Syphilis,  Cerebral 
„         Hereditary 

Syphilitic  Nodes 

Tetanus 

Thickening  of  Skull 

Thrombosis  of  Brain 

Tumour  of  Brain 

esp.  when  near  cortex 

*Uraeniia 

Ventricular  Haemorrhage 
***  In  the  '  status  epilepticus  ' 
the  seizures  follow  each 
other  in  rapid  succession 
for  perhaps  ten  or  twelve 
hours. 
To  detect  a  malingerer, 
it  is  usually  enough  to 
order  a  drastically  un- 
pleasant remedy  in  the 
hearing  of  the  patient. 


1415.  Athetosis 

Sometimes  described  as  a 
disease.  It  consists  of 
slow  successive  spasmodic 
movements  in  all  direc- 
tions, chiefly  of  the  fingers, 
but  often  involving  the 
wrist,  elbow,  and  toes 
— rarely  the  face.  The 
movements  may  continue 
during  sleep.  They  are 
sometimes  bilateral. 
Lesion  of  lenticular  ganglion 
or  near  optic  thalamus. 

Athetosis,  Primary 
bilateral 

Birth  Palsy 

Cerebral  Diplegia 
♦Cerebral  Thrombosis 

Chorea,   Post-hemiplegic 

Disseminated  Sclerosis 
*Embolism,  Cerebral 

Encephalitis 

Haemorrhage,  Cerebral  (x) 

Hemiplegia,  11. 

Hysteria 

Infantile  Hemiplegia 

Injuries  of  Brain 

Locomotor  Ataxy 

Paraplegia,  Spastic 

Tumour  of  Brain 

Hemiathetosis    is    usually 
post-hemiplegic. 


1416.  Hiccough  (Singultus) 

An  intermittent  spasm  of 
the  diaphragm.  Spastic 
contraction  of  the  dia- 
phragm also  occurs  and 
may  last  many  minutes. 
It  sometimes  takes  the 
place  of  the  rigid  rectus 
abdominis  (827). 

Addison's  Disease 

1414-1416 


392 


SPASM  AND  RIGIDITY 


Hiccough   (Singultus) — con- 
tinued 
♦Alcoholism 

Amoebic  Dysentery 

Appendicitis 

Cancer  of  Stomach 

Cholera 

Collapse  (235) 

Diabetes 

Diaphragmatic  Pleurisy 
♦Distended  Stomach 

Dysmenorrhcea 

Dyspepsia 

Enteric  Fever,  n. 

Gangrene  of  Lung 

Glands,  Caseous 

Gout 
♦Haemorrhage 

Heart  Failure 

Hepatitis 

Hydrocephalus 

Hysteria 

Intestinal  Obstruction 

Mediastinal  Tumour 


Mediastinitis,  Fibrous 
Medulla     Oblongata,     Soft- 
ening of 
Meningitis 
Mental  Emotions 
Nephritis,  Chronic 
Pancreatic  Disease 
Pericarditis 
Perihepatitis 
Peritonitis 
Pregnancy 
Septicaemia 
Spinal  Injury 
Strangulated  Hernia 
Tumour  of  Brain 
♦Typhic  State  (62) 
Uraemia 

Nystagmus  (see  Eyeballs,  489) 

1417.  Carphology        (Picking 
Bedclothes) 
Typhic  State  (62) 


TONIC  SPASM 


1418.  Cramps 

Alcoholism 

Cancer  of  Intestine 

Cholera,  Asiatic 
,,        Sporadic 

Cirrhosis  of  Kidney 

Colic 
♦Constipation 
♦Diabetes 

Unschuld's  Sign 

Dilatation  of  Stomach 
Disseminated  Sclerosis 
Ergotism 

♦Flatulence 

♦Gastro-intestinal    Irritation 


Gout 
Hernia 
Hysteria 
Intussusception 
Lead-poisoning 
Nephritis,   Chronic   (praem.) 
Occupation  Neurosis 
Poisoning  by  Arsenic,  Anti- 
mony, and  Ptomaines 
♦Pregnancy 
Sciatica 
Tetany 
Varicose  Veins 

Cramps  are  also  caused  by 
muscular  over-exertion , 
as  in  swimming. 

1416-1418 


SPASM  AND  RIGIDITY 


393 


1419.  Spastic  Contractions 
Coeliac  Disease 
tetany 

Ergotism 
Hysteria 

Internal  Spinal  Meningitis 
Occupation  Neurosis 
Paramyotonia  Congenita 
excited  by  cold 

Progressive  Muscular  Atro- 
phy 
Sciatica 

Strychnine-poisoning 
Syringomyelia 
Tetanus 
Tetany 
Thomsen's  Disease 

on  attempting  movements, 
or  when  a  muscle  is 
percussed 

Tumours  of  Cord 

(See  Rigidity,  1420,  Gait, 
1290) 

1420.  Rigidity    and    Contrac- 
tures, Active 

Early  rigidity  disappears 
during  sleep  ;  late  rigidity 
is  persistent.  Active  or 
spastic  contracture  is  pain- 
less and  can  be  overcome 
by  steady  mechanical 
traction  or  by  a  hot  bath. 
When  old,  however,  it 
passes  into  the  passive 
form.  In  the  arms,  the 
deformity  is  flexion  ;  in 
the  legs,  extension. 

Amyotrophic   Lateral   Scle- 
rosis, in. 

Bulbar  Paralysis,  m. 
limbs 


*<  Vrebellar  Disease 
nuchal 

Cerebral  Diplegia 
*Cerebro-spinal  Meningitis 

Compression  of  Cord,  Slow, 
in. 

Cord,  Transverse  Lesion  of 

Cortical  Lesions 

Disseminated   Sclerosis,   m. 

Embolism  of  Brain 

Epilepsy,  n. 

Erb's  Spinal  Paralysis 

Ergotism,  Spasmodic 

External      Spinal       Pachy- 
meningitis 

Friedreich's  Disease 

Hemiplegia 

if  early,  a  small  haemorrhage ; 
if  sudden  and  associated 
with  coma,  haemorrhage 
into  ventricles 

Hemiplegia,  Infantile 

esp.  of  adductors  and  flexors 

Hysteria 

sometimes  persisting  during 
sleep 

Hystero-epilepsy 
Ischsemic  Paralysis,  I. 
Lateral  Sclerosis,  Primary 
*Meningitis,  Internal  Spinal 
back  and  limbs 

Meningitis,     Tuberculous 
Spinal 
„  Tuberculous 

Myelitis 

Neurasthenia  (x) 
Neuritis 
esp.  arsenical 

Occupation  Neurosis 
Paralysis  Agitans,  m. 
Paramyotonia  Congenita 
1419-1420 


304 


SPASM  AND  RIGIDITY 


Rigidity  and  Contractures, 
Active — continued 
Poliomyelitis,  Acute 
^Primary  Spastic  Paraplegia 

'  clasp-knife  rigidity,'  pelvis 
moves  with  leg 

Progressive  Muscular  Atro- 
phy 
*Spasmodic  Spinal  Paralysis 

Spastic  Cerebral  Paraplegia 

Spinal    Meningeal    Haemor- 
rhage 

Syphilitic  Spinal  Paralysis 

Syringomyelia 

Tetanus 

Tetany 

esp.  of  fingers  and  toes 

Thrombosis  of  Brain 
Torticollis 
Trauma  of  Nerve 
Tumour  of  Brain 

,,        of  Spine 

Muscular  disuse  leads  to 
rigidity  of  opponents. 

1421.  Passive  Contractures 

These  do  not  disappear  dur- 
ing sleep  and  they  can- 
not be  overcome  without 
rupture  of  the  tissues. 

Arthritis,  Gonorrhceal 
,,  Rheumatoid 

Bulbar  Paralysis,  m. 
Dupuytren's  Contracture 
Ischemic  Paralysis,  11. 
Rheumatism,  Chronic 
Spondylitis 
Trauma  of  Muscle 
Tuberculous  Joints 
Tumour  near  Joint 


1422.  Kernig's  Sign 

With  the  patient  lying  on 
his  back  with  the  thigh 
flexed,  or  sitting  on  the 
edge  of  the  bed,  forced 
extension  of  the  leg  on 
the  knee  is  almost  im- 
possible. The  arms  have 
been  known  to  give  a 
similar   sign. 

Cerebellar  Hemorrhage 

Enteric  Fever 

in  children  50  per  cent. 

Meningeal  Haemorrhage 

Meningitis,  Cerebro-spinal 
,,  Postbasic 

,,  Spinal 

,,  Tuberculous 

Thrombosis  of  Lat.  Sinus 

1423.  Waxy  Rigidity 

The  limbs  offer  to  passive 
movement  a  resistance 
like  that  of  wax.  They 
remain  in  the  position  in 
which  they  are  placed. 

*Catalepsr 
Epilepsy 
Hypnosis 
Hysteria 
Melancholia 
Meningitis  (x) 
Tumour  of  Brain 

Rigidity  of  Abdominal  Muscles 

(see  827) 

1424.  Trismus 

Tonic  closure  of  lower  jaw. 
Mechanical  and  reflex 
causes  are  included  here. 

*  Abscess   near  Masseter 

Angina  Ludovici 

Brain  Tumour 

Catalepsy  (x) 

1420-1424 


SPASM  AND  RIGIDITY 


395 


Trismus — continued 

Cerebrospinal  Meningitis 
Dental  Irritation 
♦Dentition 

esp.  of  wisdom -teeth 
Epilepsy  (x) 
Epithelioma,  Oral 
Facial  Neuralgia  (x) 
Hysteria  (x) 
Intestinal  Irritation 

esp.  worms 
Meningitis,  Tuberculous  (x) 

in  adults 

Mumps 

Myositis  Ossificans 

Odontoma 

Quinsy  (x) 

Strychnine-poisoning 

rare  ;  when  present,  late 
Temporo-maxillary  Arthritis 
*Tetanus 

constant  and  early 
Tetany  (x) 
Trichinosis 
Uraemia  (x) 

1425.  Emprosthotonos 

(Body  curved  forwards) 

Cerebro-spinal       Meningitis 

(x) 
*Intrameningeal  Spinal 
Haemorrhage,  I. 
Paralysis  Agitans 
(See  Cyphosis,  812) 

1426.  Opisthotonos 

(Body  curved  backwards) 

Cerebro-spinal  Meningitis 
Hysterical  Convulsions  (x) 
neck  not  stiff 


Internal  Spinal  Meningitis 
Strychnine 

relaxed  intervals 
*Tetanus 

no  relaxed  intervals 
Tumour  of  Cerebellum 

middle  lobe 
Uraemia 

Retraction  of  Head  (see  361) 

1427.  Spasm  of  Swallow 

Adenoids 
*Hydrophobia 

no  opisthotonos 

Hysteria 

Lyssaphobia 

Neurasthenia 

Strychnine 

Tetanus 

***  It  is  often  associated  with 
Laryngismus  stridulus. 

1423.  Spasm     of     Inspiratory 
Muscles 

Epilepsy 
Hydrophobia 
*Tetanus 
Tetany 

1429.  Spasm    of    Vocal   Cords 
(Laryngismus) 
Adenoids 
Aortic  Aneurysm 
Epilepsy,  I. 

Gastro -Intestinal  Irritation 
Hydrophobia 

clonic 
Intrathoracic  Tumour 
Measles 
i       Rickets 

1424-1429 


396 


SPASM   AND  RIGIDITY 


1430.  Spasm  of  Sternomastoid 

Spasmus  nutans 

double 
Torticollis,  Spasmodic 

1431.  Spasmodic     Flexion     of 
Toes 

Cramps 
Paralysis  Agitans 

The  four  smaller  ones  only. 


1432.  Trousseau's 
non 


Phenome- 


Sudden  violent  spasm  of 
muscles  of  forearm  upon 
pressure  over  median 
nerve  and  brachial  artery. 
(See  Accouchevr,s  Hand, 
890). 

Cramps 
Tetany 


1433.  Chvostek's  Phenomenon 

A  slight  tap  over  a  muscle 
or  nerve  produces  mus- 
cular contraction ;  the 
facial  nerve  or  its  branch 
below  the  hyoid  bone  is 
usually   selected. 

Phthisis  (x) 
Rheumatoid  Arthritis 
Tetany 
Thomsen's  Disease 

spastic 
Writer's  Cramp  (x) 


1430-1433 


ELECTRICAL  REACTION 


397 


1434.  ELECTRICAL    REACTION 

1435.  Faradisation. — This  produces  contraction  of  a  muscle, 
not  directly,  but  through  its  nerve.  The  large  or  indifferent 
electrode,  moistened  -with  warm  salt  water,  should  be  placed 
upon  the  sternum,  sacrum,  or  upper  part  of  the  back  ;  the 
small  exciting  electrode  over  the  relaxed  muscle  at  one  of 
Ziemssen's  motor  points  which  are  usually  at  the  spot  where 
the  nerve  enters  the  muscle.  The  current  is  then  strengthened 
until  a  visible  muscular  contraction  is  produced.  As  cold 
slows  contraction,  care  must  be  taken  that  the  limb  is  warm. 
Note  the  degree  and  compare  one  muscle  with  another. 

1436.  Galvanic  Current. — About  30  Leclanche  cells,  or  their 
equivalent,  are  required.  Place  electrodes  as  before.  Turn 
switch  so  that  the  small  one  becomes  the  negative  pole  (kathode 
or  '  current  of  exit ').  Close  the  circuit  several  times  until  the 
minimum  strength  which  will  produce  muscular  contraction  at 
closing  (K.C.C.)  is  obtained.  Repeat  with  current  reversed  so 
that  the  small  electrode  becomes  the  positive  pole  or  anode,  get 
the  Anode  Closing  Contraction  and  compare  the  two.  The 
character  of  the  contraction,  whether  sluggish,  sharp,  or  tetanic, 
should  be  noted.  In  health  K.C.C.  (kathode  closing  contraction) 
requires  the  weakest  current,  and  K.O.C.  the  strongest;  A.O.C. 
(anode  opening  contraction)  and  A.C.C.  are  intermediate. 

The  testing  of  muscles  in  the  future  is  likely  to  be  done  by  th? 
Condenser.  This  measures  the  contractility  in  microfarads 
and  is  painless. 


1437.  Reaction    of    Degenera- 
tion (R.D.) 

Strong  but  sluggish  or 
vermiform  galvanic,  and 
diminished  or  lost  Fara- 
daic,   contractility. 

A.C.C.  =K.C.C. 

R.D.  is  not  found  in  cere- 
bral or  in  functional 
diseases.  It  occurs  in 
connection  with  disease 
of  the  peripheral  nerves, 
the  roots,  or  the  anterior 
horns,  and,  consequently, 
in     muscular     atrophies. 


In  muscular  dystrophies 
it  is  found  very  late  if 
at  all. 

Amyotrophic   Lateral  Scle- 
rosis (x) 

Atrophic    Spinal    Paralysis, 
Chronic 

Bulbar  Paralysis 

Cauda  Equina,  Lesion  of 

Compression  of  Cord 

Diphtheritic   Paralysis 

Hereditary  Muscular  Atro- 
phy 

1434-1437 


398 


ELECTRICAL  REACTION 


Reaction  of  Degeneration 
(R.D. ) — continued 
Idiopathic    Muscular    Atro- 
phy 
Injuries  to  Cord 
*Lead  Paralysis 
Myelitis 
*Neuritis,  II. 
♦Peripheral      Paralysis      in 

general 
Poliomyelitis,  Anterior 

paralysed  muscles 
Pressure  on  Nerve -trunks 
Rheumatic  Paralysis 
Spinal  Paralysis  of  Adults, 

Acute 
Syringomyelia,  n. 
Tooth's  Paralysis 
Traumatic  Paralysis 

1433.  Flora's   Myasthenic  Re- 
action 

The  affected  muscles  gradu- 
ally fail  to  respond  to 
prolonged  faradisation, 
and  only  slowly  recover 
their  power. 

Traumatic  Neurosis 


1439.  Jolly's  Myasthenic    Re- 
action 

This  consists  in  the  rapid 
temporary  loss  of  Fara- 
daic  tetanus  by  the  mus- 
cle which,  however,  still 
reacts  to  galvanic  and 
voluntary  stimuli.  The 
loss  of  excitability  is 
limited  to  an  area  near 
the  spot  stimulated. 

Eid's  Disease 
Hvsteria 


Myasthenia  Gravis 
Neurasthenia 
Traumatic  Neurosis 

1440.  Myasthenic  State 

This,  though  not  an  electri- 
cal reaction,  is  inserted 
here  for  convenience. 

A  voluntary  movement,  on 
being  frequently  repeated, 
becomes  weaker  and 
weaker  until  it  is  tempor- 
arily lost. 

Myasthenia  Gravis 

1441.  Rumpf's  Traumatic  Re- 
action 

Alternating  fibrillary  and 
tonic  contractions  after 
the  cessation  of  vigorous 
faradisation 

Traumatic  Neurosis 

1442.  Ghilarducci's     Reaction 

(R.D.d.) 

The  active  electrode  is 
placed  not  on  the  muscle, 
but  at  a  distance  ;  e.g.  on 
the  wrist  for  the  forearm. 
This  reaction  persists  long 
after  all  others  have  been 
lost,  and  its  absence  indi- 
cates a  complete  separa- 
tion from  the  trophic 
centre- 


Electric  Irritability 

1443.  Diminished 

Amyotrophic   Lateral  Scle- 
rosis 
Chorea 

Locomotor  Ataxy 
Myasthenia  Gravis 
Occupation  Neurosis,  n. 
1437-1443 


ELECTRICAL  REACTION 


399 


Electric     Irritability 
Diminished — continued 

Paralysis  Agitans,  in. 

Periodic  Paralysis 
lost  during  paroxysms 

Poliomyelitis,    Chronic    An- 
terior 
certain   muscles   only 

Progressive  Muscular  Atro- 
phy 
myopathic  form 

Syringomyelia 

1444.  Increased  (rare) 

Hemiplegia 

Locomotor  Ataxy 

Myelitis 

Occupation  Neurosis,  I. 

Peripheral  Neuritis,  I. 

Rickets 

Tetany 

with     an     anodal     opening 
tetanus  (Erb) 


1445.   Unaffected 
Cerebral  Hemiplegia 
Hysterical  Paralysis 
Psychical  Paralysis 
Transverse  Lesion  of  Cord 


1446.  Myotonic  Reaction 

The  reaction  from  either 
current  develops  and  re- 
laxes very  slowly.  A.C.C. 
is  often  stronger  than 
K.C.C. 

*Thomsen's  Disease 


1447.  Erb's  Point 

Situated  at  a  finger -breadth 
external  to  the  sterno- 
mastoid  and  two  above 
the  clavicle.  Electric 
stimulation  here  produces 
contraction  of  the  deltoid, 
biceps,  brachialis,  and 
supinator  longus. 


1443-1447 


400  THE  BLOOD 


1448.  THE  BLOOD 

The  total  weight  of  the  blood  in  an  adult  is  about  six  pounds, 
or  one-twentieth  of  the  body-weight.  The  blood  needed  for 
purposes  of  examination  should  be  obtained  from  the  ear-lobe  of 
a  fasting  or  nearly  fasting  patient ;  or  from  a  vein  direct  if 
bacteria,  etc.,  are  being  sought  for.  A  cover  glass  being  laid  upon 
a  slide,  a  drop  is  placed  at  the  edge,  so  that  the  blood  may 
be  drawn  under  it  by  capillary  attraction.  If  pressed  down 
tightly,  an  artificial  poikilocytosis  may  be  induced.  The  specimen 
is  then  examined  with  a  -jV  inch  oil  immersion  objective.  The 
most  convenient  hsemacytonieter  is  the  Thoma-Zeiss,  but  in  its 
absence  an  approximate  estimate  of  the  number  of  leucocytes 
in  each  cubic  mm.  may  be  obtained  by  the  following  formula  : 
Multiply  by  1600  the  number  of  leucocytes  visible  in  the  field  of  a 
microscope  that  magnifies  500  diameters.  An  average  must  be 
struck  from  the  examination  of  several  fields.  The  various  forms 
of  leucocytes  are  found  in  the  following  proportions  :  eosinophiles 
0*5  to  4  per  cent.  ;  basophil  cells  0*025  to  1  per  cent.  ;  large 
lymphocytes  with  single  oval  nucleus,  3  to  10  per  cent.  ;  small 
lymphocytes,  15  to  30  per  cent.  ;  polymorphonuclear  neutrophile 
leucocytes,  60  to  75  per  cent.  ;  hyaline  cells  4  per  cent.  The 
most  useful  staining  fluid  is  Jenner's.  As  soon  as  the  film  is  dry, 
a  few  drops  are  poured  on  it  and  covered  with  a  watch  glass  to 
prevent  evaporation  ;  it  is  then  left  for  2  to  4  minutes.  Rinse 
in  distilled  water  till  the  out-flow  is  pink  (10  seconds),  then 
dry  over  gentle  heat,  and  mount  in  xylol  balsam.  The  red 
cells  will  be  terra-cotta  colour,  the  nuclei  blue,  the  granules  of 
myelocytes  and  of  polynuclear  cells  red,  platelets  mauve,  mast 
cells  violet,  and  filarial  and  malarial  parasites  blue.  For 
Haematozoa,  Leishmann's  stain*is  used. 


1448 


THE  BLOOD 


401 


1449.  RED  CELLS 

The  normal  proportion  is  5  millions  to  the  cubic  millimetre  in 
males  and  4.V  in  females.  Residence  in  high  altitudes  increases  the 
number  by  100,000  for  every  330  feet.  The  red  cells  are  about  half 
the  bulk  of  the  blood  ;  in  post-natal  life,  they  are  all  formed  from 
the  red  marrow  of  the  long  bones. 


1450.  Oligocythaemia 

Diminution  in  the  number 
of  the  red  cells. 

Anaemia 

Aplastic  Anaemia 

Banti's   Disease 

Caisson  Disease 

Carcinoma 

Chloroma 

Chlorosis 

Haemochromatosis 

Haemorrhage 

Helminthiasis 

Lead-poisoning 

Leukaemia 

Lymphadenoma 

Malaria 

Pernicious  Anaemia 

sometimes    reduced    to 
400,000  or  less 

Rheumatism 
Splenic  Anaemia 
Tuberculosis 
Wasting  Diseases 


1451.    Polycythaemia       (Ery- 

throcytosis) 

Red  cells  increased   in 
number. 

Addison's  Disease 
Cholera 
Chorea 

Congenital  Heart  Disease 
6  to  14  millions 


Cyanosis  (396) 

slight  increase 
Diabetes 
Leukaemia 
Nephritis,    Chronic 
Polycythaemia,     Splenome- 

galic 

8  to  12  millions 
Trypanosomiasis 

Also,  temporarily,  after  a 
cold  bath  or  a  heavy  meal. 

It  occurs,  further,  in  some 
debilitated  conditions  as 
from  diarrhoea,  vomiting, 
sweating  and  polyuria, 
where  it  is  due  to  lessened 
fluidity  of  the  blood  by 
concentration. 


1452.  Anisocytosis 

Extreme  variations  in  the 
size  of  the  red  cells. 

Anaemia,  Severe 
*  Pernicious  Anaemia 


1453.  Macrocytes   and   Micro- 
cytes 

These  are  simply  non-nucle- 
ated red  cells  of  unusual 
size. 

Anaemia 
Chlorosis  (x) 
Pernicious  Anaemia 
2  d  1449-1453 


402 


THE  BLOOD 


1454.  Megaloblasts,        Micro- 
blasts,  Normoblasts 

Nucleated  red  cells  of  vari- 
ous sizes.  Normoblasts, 
which  are  the  size  of  an 
ordinary  red  cell  are  pre- 
sent in  the  blood  of  new- 
born infants. 

Anaemia,  Secondary 
Cancerous  Cachexia 
Chlorosis 

esp.  megaloblasts 

Congenital  Cholaemia 
Haemorrhage 
Leukaemia 
Pernicious  Anaemia 

megaloblasts  numerous 
Pseudo -leukaemia  Infantum 
*#*  Absent  in  aplastic  anaemia. 

1455.  Granular  Red  Cells 

'  Basophilic  granules ' 

Anaemia,  Tropical 
Carcinoma 

Intestinal  Decomposition 
*Lead-poisoning 
Leukaemia 
Malaria 
Pernicious  Anaemia 

1456.  Platelets    or       Deetyen 
Bodies 

Increased  in  : 

Anaemia  of  Children 

Chlorosis 

Haemorrhage 

Diminished  in  : 
Pernicious  Anaemia 


1457.  Hyaline  Cells 

12  jj.  in  diameter ;  nucleus 
horse-shoe  shaped 

Significance  unknown 

1458.  '  Ghosts  '  or  *  Shadows  ' 

Colourless  red  cells  showing 
a  double  outline. 

Haemoglobinuria  (1001) 
Pernicious  Anaemia 

1459.  Poikilocytosis 

The  red  cells  altered  in  shape; 
crenated,  pear-shaped, 
kidney-shaped,  etc. 

Anaemia,  Secondary 

Banti3s  Disease 

Cancer  of  Stomach 

Chloroma 

Chlorosis  (x) 

Congenital  Cholaemia 

Lead-poisoning 

Leukaemia 

Pernicious  Anaemia 

Splenic  Anaemia 

1460.  Colour   Index    («  Valeur 

Globulaire ') 

Divide  the  haemoglobin  per- 
centage by  the  percent- 
age of  red  cells  present 
(taking  five  millions  as 
the  normal).  Thus  if 
the  blood  contains  80 
per  cent,  of  haemoglobin 
and  two  millions  of  red 
cells,  as  two  millions  are 
40  per  cent,  of  five 
millions,  the  Colour  Index 
will  be  2   (80  -5-  40). 

The  principal  example  of 
a  '  plus '  colour  index 
is  pernicious  anaemia  and 
of  a  '  minus '  colour 
index,   chlorosis. 

1454-1460 


THE  BLOOD 


403 


WHITE  CELLS 


1461.  Leucocytosis 

Increase  in  the  number 
of  polymorphonuclear 
leucocytes.  Normally, 

7500  to  the  cubic  mm. 

Abscess  of  all  Kinds 
esp.  when  under  pressure 

Amyloid  Disease 
Anaemia,  Secondary 
Ankylostomiasis 
Appendicitis 

a  count  gradually  increas- 
ing to  35,000  means  an 
abscess 

Bronchiectasis 
Bronchitis,  Fetid 
Cachexia 
Cancrum  Oris 
Carcinoma 

except  of  gullet  or  intestine 

Cerebro-spinal  Meningitis 

Chlorosis,  n. 

Cholangitis,  Infective 

Cholera 

Cirrhosis  of  Liver 

Diphtheria 

Empyema 

Endocarditis,   Septic 

Erysipelas 

Gall-Bladder,   Emp}rema  of 

General  Paralysis 

Glanders 

Glands,  Caseous 

Gout 

Haemorrhage,  Post 

Hypertrophic  Cirrhosis 

Inflammation 

Intestinal  Obstruction 

2  D 


Lead-poisoning 
*Leukaemia 


sometimes 
four  red 


one    white     to 


Lymphadenoma 
Measles 

incubation  only 
Meningitis,  Tuberculous 
Mental  Affections,  Acute 
Myxcedema 
Osteomyelitis 
Otitis  Media 

Ovarian  Cyst,   Suppurating 
Peritonitis 
Pertussis 

Phlebitis,  Suppurating 
Phthisical  Cavity 
Plague 
Pleural  Effusion,  Simple 

slight 
Pneumonia,  Lobar 

„  Lobular 

Pseudo-leukaemia  Infantum 

with  infection 

Pyaemia 
Pylephlebitis 
Pyosalpingitis 
Rabies 

Rheumatism,  Acute 
Rickets 
Sarcoma 
*Scarlatina 
Serum  Injections 
Septicaemia 
Splenic  Anaemia 
Tetanus 

Tonsillitis,  Follicular 
2  1461 


404 


THE  BLOOD 


Letjoooytosis — continued 

Urethritis 

Variola 

Whitlow 

Yellow  Atrophy,  Acute 
There  is  a  normal  increase 
in  pregnancy  and  after 
exercise,  cold  baths,  and, 
(except  in  cancer  of  sto- 
mach) during  digestion. 
Though  present  in  most 
general  infections,  it  is 
slight  or  absent  in  measles, 
influenza,  mumps,  malaria 
enteric,  paratyphoid, 
rotheln,  varicella,  and, 
unless  secondary  infec- 
tion takes  place,  in  tuber- 
culosis. A  high  count, 
early,  implies  pyogenic 
infection. 


1462.  Leukopenia 

Diminution  in  the  number 
of  leucocytes. 

*  Aplastic  Anaemia 
*Banti's  Disease , 

Chlorosis  (x) 

Colitis,  Ulcerative 

Congenital  Cholaemia 
*Enteric  Fever 
early  symptom. 

Exophthalmic  Goitre  - 

Haemophilia 

Influenza 
*Kala  Azar  ^ 

Lymphadenoma,  n. 

Malaria 

Malta  Fever   » 

Measles 

Peritonitis,  Tuberculous 
*Pernicious  Anaemia 
3000  or  less' 


Pneumonia  (x) 
a  dangerous  form 

Splenic  Anaemia 

Starvation 

Tuberculosis,  I. 

A  leucopenia  takes  place 
during  sleep  and  it  is 
found  in  poisoning  by 
arsenic,  alcohol,  lead,  mer- 
cury and  morphia. 

1463.  Lymphocytosis 

Increase  in  the  number  of 
the  small  mono-nucleated 
leucocytes  (lymphocytes); 
but  in  many  cases  the 
increase  is  only  relative. 
They  originate  in  adenoid 
tissue.  A  normal  in- 
crease takes  place  two 
hours  after  a  meal  and 
also  during  sleep  and 
amongst  X-ray  workers. 
A  large  hyaline  lympho- 
cytosis occurs  in  malaria. 

Aplastic  Anaemia 
Banti's  Disease 
Bruhl's  Disease 
Carcinoma 
Chloroma 
Chlorosis 
Enteric  Fever 
Exophthalmic  Goitre 
Gastric  Catarrh 
Goitre 
Haemophilia 
Hooping-Cough 
Infancy,  Healthy 
*Leukaemia,  Lymphatic 
Locomotor  Ataxy 
Lymphadenoma 
Malaria 
Measles 

Mental  Affections' 
Mumps 

1461-1463 


THE  BLOOD 


405 


Lymph  oc  ytosis — continued 

Pellagra 

Pernicious  Anaemia 

Pseudoleukemia  Infantum 

Rickets 

Sarcoma 

Scarlatina 

Scurvy 

Swellings,  Glandular 

Syphilis,  Acquired 
„         Hereditary 

Trypanosoma 

Tuberculosis 
early 

***  A  decrease  in  lympho- 
cytes is  rare  unless  there 
is  a  corresponding  increase 
of  leucocytes. 

1464.  Eosinophilia 

The    granules    are    stained 
pink  by  eosin. 

Addison's  Disease 

Anaemia,  Simple  (x) 

Ankylostomiasis 
*Asthma,  Spasmodic 

Banti's  Disease 

Bilharzia 

Bone  Diseases 
*Bulloid  Eruptions 

Cancerous  Cachexia 

Dermatitis  Herpetiformis 

Dracontiasis 

Eczema 

Emphysema 

Fevers,  Convalescence  after 

Filariasis 

Gonorrhoea 
helminthiasis 

except    ascarides    and    tri- 
chocephalus 

Hydatids 


Hysteria 

Leukaemia,  Spleno-medul- 

Lithaemia  [lary 

Lymphadenoma 

Mental   Affections,    Chronic 

Neurasthenia 

Osteomalacia 

Osteomyelitis 

Ovarian  Disease 

Pemphigus 

Phosphorus-poisoning 

Phthisical  Cavities 

Pneumonia 

after  crisis 
Rheumatism,  Acute 
Rickets 

Sarcoma  of  Bone 
Scarlatina 
Skin  Affections 
Trichinosis 

It    can    be    produced    by 
taking  camphor. 

1465.  Eosinopenia 

Carcinoma 
*Enteric  Fever 
Fevers,  Other 
Haemorrhage,  Post 
Pernicious  Anaemia 

1466.  Myelocytes 

Myelocytes   are  found  nor- 
mally in  bone  marrow. 

Anaemia,  Aplastic 
Ankylostomiasis 
Carcinoma 
Chlorosis 

Leukaemia,  Spleno-medul- 
Malaria  [Ian- 

Pernicious  Anaemia 
Pseudo-leukaemia  Infantum 
Scurvy 

1463-1466 


406 


THE  BLOOD 


1467.  Basophilia  (Mast  Cells) 

These  are  about  the  size 
of  a  lymphocyte  and  con- 
tain a  number  of  granules 
which  stain  blue  with 
Jenner.  A  few  are  found 
normally. 

Acromegaly 

Anaemia,  Splenic 

Chloroma 

*Leukaemia,  Medullary 

StaphylocDccus  Infections 

It  can  be  produced  arti- 
ficially by  injecting  milk. 

1468.  Hsemoconiosis 

Blood-dust  of  Miiller.  Sig- 
nificance uncertain.  The 
particles  are  more  abun- 
dant after  a  meal. 


1469.  SPECIFIC  GRAVITY 

Normally  1055  in  men, 
1053  in  women,  and  1051 
in  children. 

Low  Sp.  Gr.  (This  is  known  as 
Hydraemia) 
Anaemias 
Anasarca 
Carcinoma 
Cholaemia,  Cong. 
Haemorrhage 
Nephritis 

*Pernicious  Anaemia  (Sp.  Gr. 
1035) 
Pregnancy 

High  Sp.  Gr. 
Cholera 

Polycythemia,      Splenome- 
galic 

up  to  1083 
Loss  of  fluids  in  general 


1470.  Haemoglobin  Increased 

Normally  100  c.c.  of  blood 
contain  13*5  grams  of 
hemoglobin. 

Hall's  Rotary  Hsemoglobin- 
ometer  is  one  of  the  best, 
but  Talqvist's  papers  are 
convenient. 

Aplastic  Anaemia 
Polycythaemia,      Splenome- 

galic 
Pulmonary  Stenosis 

1471.  Haemoglobin  Diminished 

Anaemia  (all  forms) 

Banti's  Disease 

Chlorosis 

sometimes  to  | 

Enteric  Fever 

Lead-poisoning 

Pernicious  Anaemia 

but  not  so  much  as 
the  oligocythemia  would 
seem  to  imply 

1472.  Free  Haemoglobin  (Lake 
blood) 

Haemoglobinuria,    Paroxys- 
mal 
Hyperpyrexia  (297) 
Malaria 

Phosphorus  -poisoning 
Sunstroke 


1473.  Viscosity 

Polycythemia    or 
fluid  content. 


lessened 


Cholera 
Diabetes 
Diarrhoea 
Dysentery 

Polycythaemia,      Splenome- 
galic 

1467-1473 


THE  BLOOD 


407 


1474.  Pigment  (Melanaemia) 

Addison's  Disease 
Hemoglobinuria,     Paroxys- 
mal 
Intermittent,  Pernicious 
Malaria 

Melanotic  Tumour 
Relapsing  Fever 

1475.  Hyperinosis 

Excess  of  Fibrin. 

Chlorosis 

Erysipelas 

Infectious  Diseases 

Influenza,  I. 

Phthisis 

Pneumonia 

Rheumatism 

Scurvy 

Serous  Inflammations 

Suppuration 

1476.  Hypinosis 

Deficiency  of  Fibrin 
Emphysema 
Heemoglobinuria 
Haemophilia 
Haemorrhage 
Inflammation    of   Mucous 

Surfaces 
Pernicious  Anaemia 

1477.  Glycogenic    Reaction 

The  cover  glass  is  placed 
film  upwards  under  a 
close-fitting  bell  glass, 
together  with  a  few 
crystals  of  iodine,  for 
a  few  minutes,  and  then 
mounted  in  laevulose 
syrup.  The  glycogen- 
holding  parts  are  stained 
mahogany  brown. 


Abscess,  Cerebral 

Appendicitis 

Arthritis,  Gonorrhceal 

Broncho-pneumonia 

Diabetes 

Diphtheria,   Inflammatory 

Dyspnoea,  Acute 

Empyema 

Gangrene  of  Lung 

Pneumonia,  Acute 

Suppuration 

Most  diseases  with  well- 
marked  leucocytosis  show 
the  reaction,  and  it  is 
present  in  sepsis  even 
where  there  is  none.  It 
is  absent  in  dry  or  serous 
pleurisy  and  in  uncom- 
plicated tuberculosis. 
Normal  blood  gives  a 
slight  reaction. 

1478.  Alkalinity  Increased 

The  normal  alkalinity  is 
equal  to  300  milligrammes 
of  NaHO  per  100  c.c. 

Amyloid  Liver 

Appendicitis 

Gallstones 

Gout 

Influenza 

Jaundice,  Catarrhal 

Phthisis 

Pneumonia 

Rheumatic  Fever 

Rubeola 

The  alkalinity  rises  during 
digestion  and  in  the  early 
morning. 

1479.  Alkalinity  Diminished 

Anaemia,  Secondary 
Cancerous  Cachexia 
*  Cholera 

1474-1479 


408 


THE  BLOOD 


Alkalinity     Diminished  — 
continued 
*Diabetes,  n. 
Eclampsia 
Epilepsy 
♦Enteric  Fever 
Fevers  in  General 
Gastric  Ulcer 
Leukaemia,  Splenic 
Mania,  Acute 
Paralysis,  General 
Tuberculosis 

The  condition  is  found  after 
exercise  and  whenever 
the  system  is  much 
lowered.  The  blood  has 
sometimes  been  found 
acid  in  cholera. 

1480.  Fat 

'  Strawberry-cream  blood.' 
The  normal  proportion 
is  5  per  cent. 

Diabetes 
20  per  cent. 

1481.  Acetone 

♦Diabetic  Coma 
Ulcer  of  Stomach 

1482.  Choline 

This  is  an  indication  of 
nerve  degeneration.  It 
is  not  found  in  hysteria. 

Beri-beri 
Dementia 
General  Paralysis 
Muscular  Atrophy 
Myelitis,  Transverse 
Neuritis 

Sclerosis,  Disseminated 
Syphilis,  Cerebral 
%♦  Also    after    division     of     a 
nerve. 


1483.  Cholesterln 

A  small  quantity  is  nor- 
mally present.  This  is 
increased  in  : — 

Enteric  Fever 
Gallstones 

90  per  cent,  of  cases 

Puerperal  state 
Pregnancy 


1484.  Agglutination     Test 
(Widal  Reaction) 

One  part  of  serum,  obtained 
most  conveniently  from  a 
blister,  is  added  to  200 
parts  of  a  24-hour 
bouillon-culture  of  the 
typhoid  bacillus.  The 
bacilli  quickly  lose  their 
mobility  and  clump  to- 
gether in  95  per  cent,  of 
typhoid  cases,  if  examined 
after  the  fifth  day.  The 
same  principle  has  since 
been  applied  to  other 
diseases  as  under. 

Bacillus  coli  Infection 
Cholera 

Endocarditis  (x) 
♦Enteric  Fever 

continues  long  after  recovery 

Glanders 
Malta  Fever 
Paratyphoid  Fever 

high  dilution  only 
Plague 
Ptomaine  Poisoning 

bacillus  of  Gaertner 
Tuberculosis 

Absent  injpsittacosis. 
1479-1484 


THE  BLOOD 


409 


1485.  Aniline  Reaction 

A  1  in  1000  solution  of 
methylene  blue,  alka- 
linised  with  caustic 
potash,  and  warmed, 
gives  a  yellowish-green 
tint    with    the    blood    of 

Diabetes 


1486.  Coagulation  Period 

Normally  10  minutes. 
Sloived  in  : — 

Exophthalmic  Goitre 
♦Haemophilia 
Pernicious  Anaemia 
Streptococcus  Infections 

Hastened  in  : — ■ 
Enteric  Fever 
Pneumococcal  Infections 

1487.  Freezing  Point  A 

This  is  low  in  direct  pro- 
portion to  the  quantity 
of  salts  present.  Normal 
point  —  0'56.     If  below  : 

Renal  Incompetence 


1488.  Isolysin  in  Blood 

This  was  said  to  be  diag- 
nostic of  cancer,  but  it 
has  been  found  since  in 
tuberculous  and  even  in 
healthy  subjects. 

1489.  Brieger's   Cachexia   Re- 
action 

This  depends  upon  the 
fact  that  the  serum  of 
persons  suffering  from 
cancerous  and  other 
cachexise  has  a  greater 
inhibitory     power     upon 


the  action  of  r  trypsin 
than  has  normal  serum. 
Hysterical  cachexia  gives 
no  reaction,  probably 
because  there  is  no  de- 
struction of  leucocytes. 


1490.  Wassermann  Reaction 

As  a  pure  culture  of  the 
pathogenic  agent  of 
syphilis  cannot  be  ob- 
tained, an  extract  of 
syphilitic  liver  is  em- 
ployed. This  serves  as 
the  antigen  which,  applied 
to  ordinary  blood,  pro- 
duces haemolysis ;  but, 
applied  to  blood  contain- 
ing the  syphilitic  '  anti- 
body,' does  not.  Th3 
technique  is  too  compli- 
cated for  insertion  here. 

Diabetes  (x) 
General  Paralysis 
Leprosy 

Locomotor  Ataxy 
Noma 

Osteitis  Deformans 
Raynaud's  Disease 
Syphilis,  Congenital 

even  on  day  of  birth 
Syphilis,  Primary 

40  per  cent,  only 

♦Syphilis,     Secondary      and 

Tertiary 

Trypanosomiasis 

Yaws 

If  the  patient  has  been 
taking  mercury,  a  three- 
weeks'  course  of  iodide 
is  necessary  before  the 
test  is  made. 


1485-1490 


410 


THE  BLOOD 


1491.  Stern's  Modified  Wasser- 

mann 

This  gives  a  reaction  in 
more  cases  of  primary 
syphilis  than  the  original 
test ;  but  is  positive  in 
a  larger  proportion  of 
healthy  subjects. 

1492.  Porges-Meier  Reaction 

This  is  said  to  give  the  same 
results  as  Wassermann's 
Reaction.  A  one  per 
cent,  emulsion  of  leci- 
thin in  normal  saline  is 
mixed  with  an  equal 
part  of  blood  serum  and 
allowed  to  stand  at  room 
temperature  for  five 
hours.  The  lecithin  is 
precipitated  by  syphilitic, 
but  not  by  normal, 
serum. 


1493.  Justus%Test 

A  single  inunction  of  mer- 
cury causes  a  marked 
reduction  in  the  per- 
centage of  haemoglobin. 

Syphilis 

The  test  is  of  positive 
value  only. 

1494.  Opsonic  Index 

This  is  the  difference 
between  the  phagocytic 
power  of  a  leucocyte  for 
a  given  bacillus  in  (a) 
normal  serum  and  (b) 
serum  derived  from  blood 
infected  with  that  par- 
ticular bacillus.  It  is 
expressed  by  a  vulgar 
fraction  in  which  the 
numerator  is  the  average 
number  of  bacteria  per 
leucocyte  in  the  patient's 
film  and  the  denomin- 
ator that  in  the  normal 
film:  The  index  rises  and 
falls  nearly  pari  passu 
with  the  temperature. 


1491-1494 


BACTERIA 


411 


1495.  BACTERIA,    ETC. 


1496.  GRAM'S   DIFFERENTIATING  STAIN 


The  film  having  been  spread  and  dried,  stain  for  two  or  three 
minutes  in  aniline  gentian  violet.  Rinse  in  water.  Flood  with 
Gram's  iodine  solution,  allowing  it  to  act  for  one  minute.  Finally 
wash  off  with  alcohol,  by  rocking  to  and  fro  till  no  more  colour  comes 
away. 


-97.  Gram   Positive 

1498.  Gram  Negative 

Actinomycosis 

All  Parasitic  Protozoa 

Bacillus  Acnes 

Bacillus  Coli 

B.  Anthracis 

B.  Dysenterise 

B.  Boas-Offler 

B.  Fusiformis 

B.  Klebs-Loeffler 

B.  Gaertneri 

B.  Lepras 

B.  Lactis  Aerogenes 

B.  Pyocyaneus 

B.  Mallei 

B.  Tetani 

B.  Para  typhosus 

B.  Tuberculosis 

B.  Pestis 

B.  Vaginae 

B.  Pertussis 

Favus 

B.  Pfeifferi 

Micrococcus  Epidermidis 

B.  Smegmas 

,,          Tetragenus 

B.  of  Soft  Sore 

Pneumococcus 

B.  Typhosus 

Ringworm 

Diplococcus,  Weichselbaum 

Sporotrichon  Bearmanni 

Gonococcus 

Staphylococcus 

Meningococcus 

Streptococcus 

Micrococcus  Catarrhalis 

Streptothrix 

„           Melitensis 

Yeasts 

Pneumobacillus    of    Fried - 

Keratinised          epithelium, 

lander 

calcified  particles  and  the 

Proteus  Vulgaris 

granules    of    eosinophiles 

Spirochasta  Denticola 

are  also  Gram  Positive. 

,,           Schaudinnii 

Spirillum  Choleras 

„         Obermeyeri 

1495-1498 


412 


BACTERIA 


1499.  Acid-Fast  Bacilli 

Bacillus  Leprae 
Bacillus  Smegmae 

found  normally  about 
clitoris  and  prepuce 

Bacillus  Tuberculosis 

***  B.  Smegmas  is  decolourised 
by  alcohol  ;  B.  Tuber- 
culosis is  not. 

1500.  Filtrable  Viruses 

Organisms  cease  to  be 
visible  through  any 
microscope  if  less  than 
0'3   \x  in   diameter. 


Dengue 

Measles 

Molluscum  Contagiosum 

Poliomyelitis,  Anterior 

Rabies 

Scarlatina 

Trachoma 

Typhus 

Varicella 

Variola 

Yellow  Fever 

The  list  is  provisional  as 
experts  are  not  quite  in 
agreement. 


1501.  MICROCOCCI  (spherical  bacteria) 

1  micromillimetre  (/a)  =  TiroiioTTo  °^  a  metre  or  -51^00  °£  an  inch. 
In  general,  bacteria  in  blood  are  demonstrated  by  culture  only. 


1502.  Staphylococcus  Pyogenes 

Var.  aureus,  albus,  citreus  ; 
size,  0'9  jul,  cocci  arranged 
in  clusters. 

Abscess 

Acne 

Boil 

Carbuncle 

Empyema 

Endocarditis,  Ulcerative 

Glandular  Suppuration 

Osteomyelitis 

Otitis  Media 

Pemphigus  neonatorum 

Periostitis,  Acute 

Pyaemia 

Rheumatic  Fever 

Sloughs 

***  Local     Inflammation     in 
general. 


1503.  Streptococcus    Pyogenes 
Size   1*0  jx,   cocci  arranged 
in  wavy  chains. 

Abscess,   Glandular 
„        Secondary 
Cholera,  Sporadic 
Diphtheria 
Erysipelas 

Membranous  Pharyngitis 
Peritonitis,  Puerperal 
Pneumonia 
Pyemia  (x) 
Scarlatina 
Septicaemia 
*#*  Severe    Inflammatory 
cesses  in  general. 


Pro- 


1504.  Streptococcus  Brevis 

The  adjective  applies  to 
the  chain,  not  to  the 
organism. 

Inflammatory  Affections 
Some  are  found  normally  in 
the  mouth. 

1499-1504 


BACTERIA 


413 


1505.  Streptococcus     Erysipe- 

latis 

This  is  now  believed  to  be 
identical  with  S.  Pyogenes. 

1506.  Streptococcus  Malae 

Arthritis 

1507.  Streptococcus  Conglom- 
eratus 

Scarlatina  (?) 

1508.  Streptococcus  Salivarius 
Pyorrhoea  Alveolaris 

1509.  Streptococcus  Epider- 
midis  Albus  (Morococcus 
of  Unna) 

Eczema 

1510.  Pneumococci  (Diplococ- 

cus  of  Fr'ankel) 

Small  oval  cocci  1/j.  x  0'75,u, 
often  arranged  in  pairs. 
Capsule  well  marked. 

Abscess 

„        Hepatic 
Arthritis 

Broncho  -pneumonia 
Cellulitis 
Empyema 

25  per  cent,  in  adults ;  60 
per  cent,  in  children 

Endocarditis 
Hepatic  Abscess 
Keratitis 

Mediastinitis,  Anterior 
Meningitis 
Otitis  Media 
Pericarditis,  Suppurative 
Peritonitis 


Pleurisy 
♦Pneumonia,  Acute 
Salpingitis 

A  few  are  found  in  healthy 
saliva. 

1511.  Micrococcus      Rheuma- 

ticus 

Smaller  than  Streptococcus 
Pyogenes.  In  short 
chains.     It  curdles  milk. 

Acute  Rheumatism 

Chorea 

Endocarditis 

1512.  Diplococcus  Intracellu- 
laris  Meningitidis  ( Weich- 
selbaum) 

Cerebro -spinal  Meningitis 

1513.  Meningococcus 

Post-basic  Meningitis 

1514.  Gonococcus  (Neisser) 

Like      two  beans      with 

adjacent  hila.     Usually 

contained  within    a  leu- 
cocyte. 

Gonorrhoea 

Gonorrhceal  Cystitis, 
Endometritis..  Endocar- 
ditis, Ophthalmia,  or 
Salpingitis 

Meningitis  (x) 

Septicaemia  (x) 

1515.  Micrococcus  Catarrhalis 

kidney-shaped 
Coryza 

1516.  Coccus  of  Kokubo 
Beri-beri 

1505-1516 


414 


BACTERIA 


1517.  Micrococcus    tetragenus 

Cocci  in  clusters  of  four 
Cavity  of  Phthisis  or  Bron- 
chiectasis 
Suppuration  in  Mouth 

1518.  Micrococcus  Melitensis 

SizeO'5/A  x  0*5,14 — flagellate, 
found  in  spleen 

Malta  Fever 

And  some  Indian  Fevers 


1519.  Parameningococcus 

Cerebro-spinal  Meningitis 
certain  forms  only 


1520.  Sarcina  Ventriculi 

Cocci    in    bundles    of    four 
or  multiples  of  four. 

Dilatation  of  Stomach 
Hour-glass  Stomach 


BACILLI 

Rod-shaped  bacteria 


1521.  Bacillus  Aerogenes  Cap- 

sulatus 

Size  3'0  /j.,  to  6*0  jx,  often 
occurring  in  pairs. 

Emphysema,  Interstitial 

Pneumaturia 

Pneumothorax 

1522.  Bacillus  Anthracis 

Thick  plump   rods,    encap- 
suled  and  granular. 

Anthrax 
Meningitis  (x) 

1523.  Bacillus  Acnes 

Short  rods  1*5  /x  x  0*5  (x. 

Acne 

Alopecia  Areata 
Seborrhcea 

1524.  Bacillus  Botulinus 

4    to    9    jit  xl    to    1"2  fx, 
motile. 

Botulism 


1525.  Bacillus  of  Barton 

Carrion's  Disease 

1526.  Bacillus  Coli  Communis 

Resembles  B.  typhosus,  but 
has  shorter  nagella.  It 
ferments  glucose  and  co- 
agulates milk.  Occurs 
normally  in  the  large 
bowel. 

Abdominal  Abscess 

Appendicitis 

Arthritis 

Broncho-Pneumonia 

Cholangitis 

Cholecystitis 

Colitis 

Conjunctivitis 

Cystitis 

Diabetes 

Diarrhoea,  Infantile 

Dermatitis 

Empyema 

Endocarditis 

Endometritis 

Enteritis 

1517-1526 


BACTERIA 


415 


Bacillus    Coli    Communis — 
continued 
Epididymitis 
Gastric  Ulcer 
Mastitis 

Membranous  Colitis 
Meningitis 
Otitis  Media 
Pancreatitis 
Peritonitis 
Pleurisy 
Pneumothorax 
Prostatitis 
Pyelitis 
Pyelonephritis 
Septicaemia  (x) 
Sigmoiditis 
Summer  Diarrhoea 
Urethritis 

1527.  B.  Dysenteriae 

Diarrhoea,  Summer 
Dysentery,  Bacillary 

1528.  Bacillus,  Comma 

See  Spirillum  Cholerce 

1529.  Bacillus  of  Ducrey 

Size  1*5  /J.  x  0*5  jj.  ;    minute 
rods. 

Soft  Sore 

1530.  B.  Enteritidis  ( Aertrycke) 
Food   Poisoning 

Psittacosis 
It  originates  in  Swine  Fever. 

1531.  B.  Enteritidis  (Gaertner) 
Ptomainism 

1532.  B.  Enteritidis  Sporogenes 

Summer  Diarrhoea 


1533.  Bacillus  Filiformis 

(Boas) 
Cancer  of  Stomach 

1534.  Bacillus  Fusiformis 
6-12  /j.  long ;    flagellate. 

Hospital  Gangrene 
Syphilis 
*  Vincent's  Angina 

***  But  present  in  80  per  cent, 
of  normal  throats. 

1535.  Bacillus    of   Friedlander 

(Pneumobacillus) 

Short  capsulated  rod  with 
rounded  ends, 

Acute  Pneumonia 

not  causative 

Appendicitis 

Empyema 

Meningitis 

Pyaemia 

1536.  Bacillus  Hodarse 

1  x  6  fi  x  3  fi. 
Trichorrhexis  Nodosa 

or       '  Hodara's       Disease 
which     some     think     is 
distinct  from  this. 


1537.  Bacillus  of  Hoffmann  (or 

B.  Pseudodiphtherise) 

Short,  motile,  wedge-shape, 
arranged  in  pairs  base 
to  base ;  not  beaded 
after  staining.  Found 
sometimes  in  healthy 
throats. 

Diphtheria  (x) 

1526-1537 


416 


BACTERIA 


1538.  Bacillus  of  Hansen 

Resembles  B.  tuberculosis, 
but  is  shorter  and  stains 
without  warming. 

Leprosy 

1539.  Bacillus     of     Klebs- 
Loeffler 

3'0  fi  x  3-6  fi.  Straight  or 
slightly  curved,  ends 
clubbed ;  non-motile ; 
beaded  after  staining. 
The  swab  should  be 
rotated  on  the  false  mem- 
brane and  not  allowed  to 
touch  any  other  part  of 
the  oral  cavity.  The 
bacillus  is  difficult  to 
obtain  alone  except  from 
a  culture  specimen  on 
serum. 

♦Diphtheria 

1540.  Bacillus  of  Koch- Weeks 

Conjunctivitis 

1541.  Bacillus     Lactis     Aero- 
genes 

Normal  in  the  stools  of 
infants. 

Emphysema  of  Skin  (x) 
Gangrene  of  Lung 
Pneumothorax   (x) 
Pneumaturia 
from  catheter 

1542.  Diplo-Bacillus  of  Morax- 
Axenfeld 

Angular  Conjunctivitis 

1543.  Bacillus  Mallei 

Like    B.    tuberculosis,    but 
thicker   and   stains  more 
easily,  motile. 
Glanders 


1544.  Bacillus  Paratyphosus 

It  ferments  glucose. 
Paratyphoid    Fever 

|  1545.  Bacillus  Pestis 
Plague 

1546.  Bacillus  of  Pfeiffer 

Size  1*5^  xO'3/a.    Straight 
with  rounded  ends. 

Influenza 

Meningitis 

Pysemia 

'  1547.  Bacillus     Pertussis     of 
Bordet  and  Gengou 
small  ovoid 
Hooping  Cough 

1543.  Bacillus  Pyocyaneus 

Abscess 
Empyema 
Impetigo 

Pemphigus  neonatorum 
Suppuration 
*#*  Discharge  bluish. 

1549.  Bacillus  Proteo-Vulgaris 

Cholera  Infantum 

Cystitis 

Ozsena 

Peritonitis,  Purulent 

Pyelitis 

1550.  B.  of  Rhinoscleroma 

Rhinoscleroma 

1551.  Bacillus  Segmentosus 
Coryza 

1538-1551 


BACTERIA 


417 


1552.  Bacillus  of  Shiga 

*Dysentery 

Summer   Diarrhoea    of    In- 
fants 

1553.  Bacillus    Tuberculosis 
(Human) 

Rods  3*0,u  x  0'3/j.  acid-resist- 
ing. Straight  or  slightly 
curved. 

This  is  the  one  bacillus  the 
.  detection  of  which  is 
indispensable.  As  with 
others,  a  T^  inch  oil  im- 
mersion objective  is 
desirable.  Two  solutions  : 
(a)  a  steaming  hot  solu- 
tion of  Ziehl's  Carbol- 
Fuchsin ;  (b)  a  solution 
composed  of  solid  Methy- 
lene Blue  2  grammes  and 
water  75  cc. 

Stain  the  smear  for  one  or 
two  minutes  with  solution 
a ;  wash  in  water. 
Next  place  it  for  half  to 
one  minute  in  solution 
b,  and  finally  wash  well 
with  water.  The  tubercle 
bacilli  are  stained  red ; 
others  blue.  Bacillus 
Smegmse  gives  much  the 
same  reaction,  but  is 
decolorised  by  alcohol, 
while  B.  tuberculosis  is 
not. 

When  the  bacillus  is  difficult 
to  find,  the  sputum 
should  be  boiled  with  an 
equal  quantity  of  liquor 
potassae  (5  per  cent.) 
and  centrifuged  after 
dilution. 

Erythema  Induratum 
Lupus  Vulgaris 
Meningitis,  Tuberculous 


cerebro-spinal  fluid 


Tuberculosis  of  Bowel 
in  faeces 

Tuberculosis  of  Kidney  or 
Bladder 
in  urine 

Tuberculosis  of  Lungs 
in  sputa 

Tuberculosis        Verrucosa 
Cutis 

Only  a  few  bacilli  are  found 
in  caseous  material  and 
in  Acute  Miliary  Tuber- 
culosis. 

1554.  B.  Tuberculosis  (Bovine) 
This  is  shorter,  thicker 
and  more  regular  in  size 
than  the  human  form. 
Rare  in  adults.  It  is 
found  amongst  children 
in — 

Abdominal  Tuberculosis 
50  per  cent. 

Bone  and  Joint  Tuberculosis 
50  per  cent. 

Empyema 

3  per  cent. 

Glands,  Tuberculous 

Lupus 

50  per  cent. 

It  is  rarely  found  in  pul- 
monary tuberculosis. 

1555.  Bacillus  Typhosus 

Size  2  to  4/t  x  0*5^. 

Rounded  extremities,  long 
wavy  flagella ;  found  in 
the  spleen,  ulcers,  etc., 
but  in  stools  by  culture 
only.  It  does  not  fer- 
ment glucose  nor  coagu- 
late milk. 


Abscesses,  Typhoid 

1552-1555 


418 


ORGANISMS 


Bacillus  Typhosus — contd. 
Cholecystitis  Typhosa 
Endocarditis,  Ulcerative 
*Enteric  Fever 
Osteomyelitis 

Periostitis,  Acute  Suppura- 
tive 


1556.  Bacillus  Tetani 

Size  4-0  x  0'4.  Drum- 
stick, with  slightly  motile 
flagella. 

Tetanus 

1557.  Bacillus  (unnamed) 

Bell's  Mania 


OTHER  ORGANISMS 


1558.  Amoeba  Dysenterise 

Dysentery,  Amoebic 

1559.  Filaria  Sanguinis  Horn- 
in  is 

The     larval     form     of     F. 
Bancroftii 

Ohyluria 
Filarial  Abscess 

abdomen,    limbs,    scrotum, 
thorax 

Hematuria 

obstruction  of  blood-vessels 

1560.  Filaria  Nocturna 

Found  at  night  only. 

Elephantiasis 

obstruction     of     lymphatic 
vessels 

1561.  Filaria  Medinensis 

Furunculosis 

***  Filaria  Gigas  is  said  to  be 
a  myth. 

1562.  Hsemamoeba  Malariae 

invades  the  blood-cell. 
Carried        by        Anopheles 
claviger. 

Ague 

A  double  tertian  infection 
means  a  daily  or  quotidian 


fever.  With  a  double 
quartan  infection  there 
will  be  one  free  day  a 
week. 

Herpes  Zoster 

Plasmodium  in  40  per  cent, 
of  cases  in  U.S.A. 

Malaria,  Malignant 
or  hsemominas  prsecox. 

1563.  Myxococcidium     Stegc- 

myise 

carried  by  Stegomyia 
fasciata 

Yellow  Fever 

1564.  Spirillum  Cholerse 

Comma  shaped,  size  1*5 
to  2  fx.  x  0*5  fi.  When 
paired  they  appear  S 
shaped. 

Cholera,  Asiatic 

1565.  Spirillum  Obermeyeri 

Relapsing  Fever 

1566.  Spirillum  Duttoni 

African  Tick  Fever 

1567.  Spirochseta  Pertenuis 
Yaws 

1555-1567 


ORGANISMS 


419 


1568.  Spirochaeta    Pallida    or 
Treponema        Pallidum 

(Schaudinn) 
Obtained  with  ease  by 
puncturing  syphilitic 
glands.  It  differs  from 
other  spirochetes  in 
retaining  its  spiral  form 
even  when  at  rest.  Ex- 
tremities pointed ;  4  to 
20  curves. 

General  Paralysis 

found  in  brain  after  apo- 
plectiform seizures 

Locomotor  Ataxy 

*Syphilis 

Congenital,  primary  and 
secondary,  less  evident  in 
tertiary. 

1569.  Spirochaeta  Buccalis 

Stomatitis,  Severe 

1570.  Spirochaeta  Denticola 

Vincent's  Angina 

1571.  Spirochaeta  Refringens 

A  larger  spiral  with  fewer 
curves  than  S.  pallida 

Simple  Ulcers 
Smegma  Preputii 


1572.  Leishmannia 
Kala  Azar 


Donovani 


1573.  Leishmannia  Infantum 
Kala  Azar 

(Mediterranean  form) 

1574.  Streptothrix  Gibsonii 

Splenic  Anaemia  (?) 

1575.  Streptothrix  Madurae 

Madura  Foot,  etc. 


1576.  Leptothrlx  Buccalis 
Caries  of  Teeth 

1577.  Actinomyces 

Actinomycosis 


1578.  Sporotrichon 
manni 

Sporotrichosis 


Beur- 


2  e 


1579.  Blastomyces 

Dermatitis,  Blastomycetic 

1580.  Protozoon,  Pear-shaped 

Paroxysmal      Haemoglobin- 
uria  (?) 

1581.  Trypanosoma  Gambiense 

Sleeping  Sickness 

Carried  by  Glossina  palpalia 
and  other  species. 

1582.  Trypanosoma  Brucei 

Nagana  (animals  only  ?) 

Carried   by    Glossina    mor- 
sitans 

1583.  Oidium    Albicans    vel 
Lactis 

Pharyngomycosis 
<  Phthisis  '  of  Ceylon 
Thrush 

1584.  Guarnieri  Bodies 

Varicella 
Variola 

1585.  Negri's  Corpuscles 
Found  in  brain,  etc. 

Rabies 

(See  also  Skin,  356  ;  Stools, 

1108;  Sputa,  1185;  Urine, 

1060) 
2  1568-1585 


420 


PALPATION 


Yin.  12. — Some  of  the  Principal  Viscera  inJ3it& 
(From  Gray's  '  Anatomy!') 


PART  III 


PALPATION 


Contractions  :    u,  usually ;    x,  exceptionally ;    *,  the  most  likely 
diseases  ;   i,  First  stage  ;   n,  Second  stage  ;   ni,  Third  stage. 


1586.  PALPATION   OF   THE  CHEST 


Note. — The  symptoms  which  are  elicited  by  Palpation,  Percus- 
sion, and  Auscultation  are  commonly  classed  as  physical  signs  ; 
but  no  useful  object  is  served  by  this.  The  expression  is  at  least 
equally  applicable  to  symptoms  elicited  by  the  thermometer,  the 
sphygmanometer,  the  battery,  and  even  the  weighing  machine. 


1587.  Tactile  Fremitus 

The  usual  method  is  to 
place  the  flat  of  the  hand 
on  the  chest  while  the 
patient  says  99.  Low 
pitched  sounds  are  con- 
ducted the  best. 


1588.  Increased 

That   on  the  right   side  is 
normally  more  marked. 

Abscess  of  Lung 
Actinomycosis 
Bronchiectasis 
Broncho -pneumonia  (x) 

when     the     patches     have 
become  confluent 

Cavity,  Thin-walled  (x) 
Cirrhosis  of  Lung 


Collapse  of  Lung 
Congestion  of  Lungs 
Phthisis,  I. 
*Pneumonia,  Acute 

unless   the   bronchioles   are 
plugged 

Pulmonary  Apoplexy 
Syphilitic  Lung 
Tumour,  Mediastinal 


1589.  Diminished 
Emphysema 
Empyema 
Hydatids 
(Edema  of  Lung 
Pleura,  Cancer  of 
,,       Thickened 

1586-1589 


422 


PALPATION 


Tactile    Fremitus    (Dimin- 
ished)— continued 
♦Pleural   Effusion 

unless  thick  bands  connect 
the  two  layers  of  the 
pleura 

Pneumothorax 

Also  occlusion  of  main 
bronchus  by  aneurysm 
or  intrathoracic  tumour. 
Sometimes,  too,  when 
pneumonic  or  phthisical 
consolidation  is  extremely 
dense. 


1590.  Rhonchal  Fremitus 

Asthma 
Bronchiectasis 
♦Bronchitis 
Bronchus    incompletely 

Plugged 
Cavity,  Full 

1591.  Friction  Fremitus 

(Rare) 
*Acute  Pleurisy 

ceases  when  breath  is  held 
Pericarditis 


1589-1591 


THRILL— HEART'S  IMPULSE 


423 


1592.  THRILL 

A  thrill  should  be  felt  for  where  the  corresponding  murmur  is 
best  heard.  A  soft  thrill  is  termed  '  fremissement  cataire,'  from 
its  resemblance  to  the  purring  of  a  cat. 


1593.  Systolic  Thrill 
Anaemia,  Profound 
second  left  space 

Aneurysm  of  Aorta 
Aortic  Stenosis 

at  second  right  space 
Atheroma 
Exophthalmic  Goitre 

second  left  space 
Mitral  Regurgitation 

at  apex 
Pulmonary  Stenosis 

second  left  space 
Tricuspid  Regurgitation 

at  lower  part  of  sternum 


1594.  Diastolic  Thrill 
Aortic    Regurgitation 

second  right  space 

Patent  Duct 

second  left  space 

Tricuspid  Stenosis  (x) 

1595.  Presystolic  Thrill 

*Mitral  Stenosis 

rough 

It  disappears  when  auricular 
fibrillation  supervenes. 

1596.  Epigastric  Thrill 

(Rare) 
Dilatation  of  Stomach 


1597.  HEART'S  IMPULSE 

The  heart's  impulse  corresponds  in  time  with  the  first  part 
of  ventricular  contraction — the  compression  period,  and  ceases 
to  be  felt  when  the  expulsion  of  the  blood  begins.  The  whole 
systole  occupies  -f-  of  a  second,  the  compression  period  alone 
y1-  second.     The  diastole  occupies  -fn  of  a  second. 

The  apex  should  be  felt,  normally,  two  inches  below  and 
one  inch  to  the  inner  side  of  the  nipple  (Chart  I.  M.  ox).  In 
children  it  is  in  the  fourth  space  (M.  4x),  and  changes  greatly 
with  decubitus,  at  seven  years  of  age  the  difference  between 
right  and  left  lateral  decubitus  being  nearly  one  inch  laterally. 
At  fifteen  years  of  age  it  is  in  the  adult  position,  while  in  old  age 
it  lies  in  the  sixth  space. 

To  localise  the  impulse,  the  flat  of  the  hand  should  first  be 
applied  to  the  chest ;  afterwards,  the  exact  spot  may  be  found 
with  the  forefinger,  the  patient  leaning  forward. 

Allowance  must  be  made  in  cases  of  chest  deformity  or  spinal 
curvature. 

1592-1597 


424 


HEART'S  IMPULSE 


1598.  Displaced  Upwards 

Abdominal  Tumours 

Abscess,  Subphrenic 

Ascites 

Atrophy  of  Heart 

Contraction  of  a  Vomica 

in  left  apex 

Distended  Stomach 
Enlarged  Left  Lobe  of  Liver 
Enlarged  Spleen 
Faecal  Accumulation  (x) 
Hernia,  Diaphragmatic 
Hydatids  of  Liver 

left  lobe 

Idiopathic    Dilatation    of 

Colon 
Pericardial  Effusion 

unless    the   heart   is    much 
hypertrophied 

Pleural  Effusion,  Extensive 

Right 
Pregnancy 
Tympanites 


1599.  Displaced  Downwards 

Aneurysm  of  Heart 
*Aortic  Regurgitation 
,,       Stenosis  (x) 

Cardioptosis 

Chlorosis 
♦Cirrhosis  of  Kidney 

Emphysema 

Hepatoptosis 
♦Hypertrophy  of  Heart  (1829) 

Nephritis,  Chronic 

Old  Age 

Pericardium,  Adherent 

Pneumothorax,  Left 

Tumour  at  Base  of  Heart 


1600.  Displaced  to  Right 

Atrophy  of  Heart 
Cirrhosis  of  Right  Lung 
Collapse  of  Right  Lung 
Contraction  of  Right  Lung 
1  Cor  Mobile  ' 
Diaphragmatic  Hernia 
Emphysema 
Mediastinal  Tumour 

if  of  left  side,  by  pressure ; 
if  of  right  side,  by  occlu- 
sion of  that  bronchus 

Phthisis  (x) 

contraction  of  vomica  in 
right  lung 

Pleural  Effusion,  Left 
Pneumonic      Consolidation, 

Left 

but  only  when  very  extensive 

Pneumothorax,  Left 
Transposition  of  Viscera 

1601.  Displaced  to  Left 
Abdominal  Tumours 
Aneurysm  of  Aorta 

,,  of  Heart 

Aortic  Regurgitation 

„      Stenosis  '• 

slightly 
Ascites 
Chlorosis 
*  Cirrhosis  of  Kidney 
,,         of  Left  Lung 
Collapse  of  Left  Lung 
Contraction  of  Left  Lung 
Exophthalmic  Goitre,  Old 
*Hypertrophy  of   Left  Ven- 
tricle (1829) 
Liver,  Enlarged 
Lordosis  (813) 
*Mitral  Regurgitation 

1598-1601 


HEART'S  IMPULSE 


425 


Displaced     to    Left  —  con- 
tinued 
Pericardium,  Adherent 
Phthisis  (x) 

contraction  of  vomica  in 
left  lung 

Pleural  Effusion,  Right 
Pleurisy,  Old  Left 

contraction  of  lung 
Pneumothorax,  Right 
Tumour    of    Left    Side    of 

Mediastinum 

if  left  bronchus  is  occluded 
Tumour  of  Right  Lung 

„      of     Right    Side    of 

Mediastinum 
Tympanites 

1602.  Cor  Mobile 

The  apex  shifts  with  gravi- 
tation. The  condition  is 
normal  in  children,  but 
only  to  a  slight  extent  in 
adults. 

Hydropericardium 
Pneumopericardium 
Pneumothorax,  Left 
Tumour  at  Base  of  Heart 


1603.  Diffused  Impulse 

Adherent  Pericardium 
Aneurysm  of  Desc.  Aorta 
Aortic  Regurgitation 
Beer  Drinker's  Heart 

*Dilatation  of  Heart 

*Fatty  Degeneration  of  Heart 
Hypertrophy,     Excentric 

Left 
Hypertrophy,  Right 
Mitral  Stenosis,  in. 


Pericardial  Effusion 
undulating 

Shrinking      of      Precordial 
Lung 

Tumour  in  Posterior  Medi- 
astinum 

1604.  Force  Increased 

A  strong  impulse  does  not 
necessarily  mean  strong 
ventricular  contraction. 

Acute  Endocarditis 
Albuminuria,  Postural 
Aneurysm    of    Desc.    Aorta 
'  double  jog  ' 

Aortic  Stenosis 
Apoplexy 
Atrophy  of  Lungs 
Cirrhosis  of  Kidney 
*Left  Hypertrophy  (1829) 
'  heaving  impulse  ' 

Mediastinal  Tumour 
Mitral  Regurgitation 
Myocarditis,  Acute 
Palpitation 

'  knocking,'   not   '  heaving  ' 

Pyrexia  (295) 

1605.  Double    Impulse 

Alternate         Ventricular 

Systoles 
Hemisystole 

1606.  Weak  Impulse 

The  weak  impulse  of  dilated 
ventricle  is  due  to  in- 
complete emptying. 

Aneurysm  of  Heart 
Atrophy  of  Heart 
Cardiac  Depressants 

1601-1606 


426 


HEART'S  IMPULSE 


Weak  Impulse — continued 
Contraction  of  Right  Lung 
Dilatation  of  Heart 
Emphysema 

Fatty  Degeneration  of  Heart 
Myocarditis,  Acute,  ni. 
Obesity 
Pericardial  Adhesions 

„  Effusion 

Precordial    Overlapping    of 
Lungs,  Increased 


Prostation  (234) 
Thick  Parietes 

*+*  The  impulse  is   sometimes 
impalpable  in  health. 

1607.  Sander's  Sign 

An    undulatory    precordial 
impulse. 

Adhesive  Pericarditis 
Abnormal  Pulsation  (see  289) 


1606-1607 


PALPATION  OF  ABDOMEN  427 


PALPATION     OF    THE     ABDOMEN 

1608.  The  most  difficult  region  to  explore  is  the  abdomen, 
especially  in  fat  subjects.  To  detect  the  fluctuation  of  ascites, 
or  of  a  large  cyst,  the  nurse  should  be  directed  to  place  the 
edge  of  her  hand  in  the  mesial  line  ;  the  left  hand  of  the  investi- 
gator is  then  placed  flat  on  one  flank,  while  the  finger  of  the 
other  hand  is  flicked  against  the  opposite  flank.  A  wave  will 
be  felt  if  much  fluid  be  present  ('  transmitted  thrill').  If  the 
quantity  is  very  small,  it  may  be  detected  by  the  thrill  at  the 
inguinal  rings. 

Palpation  in  general  is  effected  by  placing  the  flat  of  the 
hand  upon  the  abdomen  and  combining  firm  and  even  pressure 
with  a  movement  of  circumduction.  The  physician's  hand 
must  be  warm,  and  the  patient  must  breathe  naturally  ;  and 
to  keep  the  abdominal  muscles  relaxed,  he  should  lie  on  his 
back  with  his  shoulders  high,  his  knees  drawn  up,  and  his  mouth 
open,  or  as  an  alternative  adopt  the  knee-elbow  position. 

1609.  Retractive  Palpation.  —  I  suggest  this  name  for  a 
method  of  palpation  which  I  have  found  very  useful  in  detecting 
adhesions.  The  two  fore-fingers,  in  dorsal  contact,  are  pressed 
deeply  into  the  abdomen  and  then  separated,  the  pressure 
being  kept  up  all  the  time.  If  the  separation,  but  not  the 
pressure,  elicits  pain,  adhesions  are  present. 

1610.  Spleen. — Stand  on  the  patient's  right ;  lay  the  flat 
of  the  right  hand  upon  the  left  hypochondrium  with  the  fingers 
tucked  under  the  costal  margin  and  those  of  the  left  hand 
behind,  on  the  level  of  floating  ribs.  Then  endeavour  to  push 
the  organ  forward  during  inspiration.  Exert  increasing  pressure 
of  the  right  hand  with  each  expiration,  and  try  to  feel  the  notch 
with  each  inspiration.  Try  again  with  the  patient  leaning  over 
to  the  right. 

1611.  Liver. — The  liver  is  palpated  with  the  right  hand, 
an  endeavour  being  made  to  insinuate  the  radial  border  of  the 
hand  under  the  costal  cartilages,  the  patient  being  asked  to 
take  a  deep  breath.  The  character  of  the  edge  and  surface 
must  be  noted.  The  gall  bladder  must  be  felt  for  at  the  outer 
edge  of  the  right  rectus  near  the  ninth  costal  cartilage. 

1608-1611 


428 


PALPATION  OF  ABDOMEN 


1612.  Dipping. — This  consists  in  a  sudden  deep  pressure 
with  the  fingers,  so  as  to  take  the  abdominal  muscles  by  surprise, 
and  is  specially  useful  when  a  tumour  or  enlargement  is  disguised 
by  the  presence  of  fluid. 

1613.  Movable  Kidney. — The  patient  should  sit  up,  lean 
forward  with  the  back  arched,  take  a  deep  inspiration  and  then 
hold  the  breath  ;  the  physician  meanwhile  pushes  the  organ 
forward  with  one  hand  and  palpates  with  the  other. 

1614.  Tumour. — If  a  tumour  should  be  discovered,  the 
additional  points  to  elucidate  are  its  size,  shape,  and  movability, 
and  the  presence  or  absence  of  fluctuation  and  pulsation.  Also 
whether  it  can  be  traced  into  the  pelvis  or  into  the  loins  ; 
whether,  like  a  fsecal  accumulation,  it  can  be  made  to  pit  upon 
pressure  ;  and  whether,  like  tumours  connected  with  the  liver 
and  spleen,  it  rises  and  falls  with  respiration.  The  examination 
is  facilitated  by  the  previous  administration  of  an  enema,  and 
still  more  by  an  anaesthetic.  Examination  while  the  patient 
is  immersed  in  a  hot  bath  has  also  been  recommended.  It  is 
not,  however,  very  convenient,  and  I  have  substituted  success- 
fully the  previous  application  of  an  indiarubber  hot-water 
bottle  to  the  abdomen.  In  either  case  rigidity  must  be  looked 
for  first.     (See  also  Gaseous  Test,  1706.) 


1615.   ABDOMINAL  TUMOUR  AND  SWELLINGS 

When  large,  pelvic  tumours  become  abdominal,  and  abdominal 
tumours  central. 


1616.  Central 

Abscess,  Subphrenic 
Aneurysm 

Cancer    (  Intestine 

or  Omentum 

- 

Colloid       Pancreas 
of  I   Stomach 

Carcinoma   Ventriculi    Dif- 

fusum 
'  india-rubber  bottle  stomach  ' 

Cirrhosis  of  Stomach 

Enchondroma 

Fatty  Tumour  of  Omentum 

Gestation,  Extra -uterine 


Henoch's  Purpura 

an  effrision  into  intestinal 
wall  sim^ating  intussus- 
ception. 

Hypertrophy  of  Pylorus 
Intussusception 
sausage  shape 
Lumbar  Abscess  (x) 

„        Glands,  Enlarged 
Mesenteric  Cysts 

„        Fibromyoma 
„         Glands,  Enlarged 
Omental  Gland,  Enlarged 

,,  Tumour 

Ovarian  Cyst,  Large 

1612-1616 


PALPATION  OF  ABDOMEN 


429 


Central  Tumours — continued 
Pancreatic  Cyst 
Pancreatitis 

sometimes  secondary  to 
mumps 

Peritonaeal  Lesser  Sac 

effusion  into 
Peritonaeum,  Thickened 
Peritonitis,  Encysted 
Phantom  Tumour 
Post-peritonaeal  Abscess 

„  „  Lipoma 

Post-peritonaeal      Sarcoma, 

(Lobstein's  Cancer) 
Stomach,  Sarcoma  of  (x) 
Tabes  mesenterica 
Urachal  Cyst 
Uterus,  Gravid 

%*  Contraction  of  the  rectus 
muscle  may  be  mistaken 
for  a  tumour ;  as  also 
may  a  distended  bladder. 
The  gravid  uterus  emerges 
from  the  pelvis  in  the 
fourth  month  and  reaches 
the  umbilicus  at  the  sixth 
month. 

1617.  Lateral 

Actinomycosis 

Appendicitis 

Cancer  of  Caecum,    Sigmoid, 

or  Colon 
Cystic  Kidney,  Large 

nodular 

Diverticulum,  Inflamed 

Meckel's 

(present  in  2  per  cent,  of 
bodies;  swelling  in  left 
iliac  region) 

Dysentery- 
doughy  colon 


Encephaloid  Kidney 
Faecal  Accumulation 

pitting  on  pressure 
Gall-bladder,  Distended 
Glands,  Enlarged 
Haematocele,  Pelvic 
Haematoma,  Abdominal 
Haematosalpinx 
Hydatids  of  Liver  or  Kidney 
Hydronephrosis 

variable 

Hydrosalpinx 
Hy  pernephrom  a 
Intussusception 
Kidney,  Hypertrophied 
„        Tuberculous 

s.  palpable 
Movable  Kidney 

12  right  to  1  left 

Omental  Tumours  (x) 
Ovarian  Cyst,  etc. 
Parasite  of  Kidney 
Pelvic  Abscess 
Perinephric  Abscess 
Psoas  Abscess 
Pyelonephritis 
Pyonephrosis 

variable 

Pyosalpinx 
Riedei's  Lobe 
Sarcoma  of  Kidney 
Sigmoiditis 
Spasm  of  Colon 
'  stiffened  area  ' 

Spasm  of  Pylorus 
Spleen,  Dislocated 

„        Enlarged 
Suprarenal  Tumour 
Tuberculosis  of  Caecum 

1616-1617 


430 


PALPATION  OF  ABDOMEN 


Lateral  Tumours — continued 

Ureter,  Distended 

Doubtful  cases  should  be 
examined  after  an  enema 
under  an  anaesthetic. 
Gurgling  may  be  felt  over 
tumours  connected  with 
the  kidney  or  pancreas ; 
when  in  doubt,  gaseous 
distension  should  be  em- 
ployed.    (See  1706) 


1618.  Fluctuating 

(or  transmitted  thrill) 
Abscess  in  Abdominal  Pari- 

etes 
Ascites 
Distended  Bladder 

slightly  so 

^Ectopic  Gestation 
Effusion   into   Lesser    Peri- 

tonseal  Cavity 
Gall-bladder,  Distended 
Hydatids 
Hydronephrosis 
Hydrosalpinx 
Lumbar  Abscess  (x) 
Ovarian  Cyst  (x) 
Peritonitis,  Encysted 
Pregnancy 
Pyonephrosis 
Pyosalpinx 


1619.  Impulse    in    Groin    on 
Coughing 
Hernia 

Psoas  Abscess 
Varix,  Saphenous 

Also  some  cysts. 


1620.  BologninPs    Symptom 

A  feeling  of  crepitation 
when  gradually  increasing 
pressure  is  made  upon  the 
abdomen. 

Measles 

from  prodromal,  to  end  of 
eruptive,  stage 


1621.  Traced  into  Pelvis 

Abscess,  Ovarian 

Cyst  of  Broad  Ligament 

Distended  Bladder 

sometimes   enormous   in 
women 

Extra -uterine  Foetation 
Fibrocystic       Tumour      of 

Uterus 
Fibroid  Tumour  of  Uterus 
Hsematosalpinx 
Hydrometra 
Hydrosalpinx 
Hypertrophied  Bladder 
Menses,  Retained 
Myoma 

Ovarian  Cyst  or  Tumour 
Pericystic  Abscess 
Peritonseal  Hydatids 
Polypus 

Pregnancy,  Early 
Pyosalpinx 
Subinvolution 
Tubal  Cancer  or  Tubercle 
Uterine  Congestion 

1622.  Movable  on  Palpation 

Aneurysm,  Coeliac 

Caecum  Mobile 

Concretions 

Cyst  of  Tail  of  Pancreas 

Faecal  Accumulation 

1617-1622 


PALPATION  OF  ABDOMEN 


431 


Movable    on    Palpation  — 
continued 
Floating  Kidney 

'  cinder-sifting  mobility  ' 

Floating  Liver 

„        Spleen 
Gall-bladder,  Distended 
movable  laterally 

Intestinal  Growths 
Ovarian  C}Tst 
with  long  pedicle. 

Pyloric  Growth 

RiedeFs  Lobe 

Tumour  of  Sigmoid  Flexure 
„  of  Small  Intestine 
„  of  Transverse 
Colon 

1623.  Fixed   on   Palpation 

Abscess,  Appendicular 

„        Spinal 
Aneurysm 

Glands,  Retroperitonaeal 
Hydronephrosis 
Pancreas,  Tumour  of 
Pyonephrosis 
Suprarenal  Sarcoma 

***  Other  tumours  when 
adherent  to  parietes  or 
to  fixed  organs  * 

1624.  Movable  with  Respira- 
tion 

Cancer  of  Stomach 
infiltrating       greater      cur- 
vature 

Cancer  of  Transverse  Colon 
Gal  1-bladder,        Enlarged 

(1633) 
Hypernephroma 
Liver,  Enlarged 
„     Growths  on 


Liver,  Hyatids  of 
Omental  Peritonitis 
Ovarian  Tumour  (x) 
Renal  Tumour,  Large 

slightly 

Spleen,  Enlarged 
Splenic  Growths 
Supra-renal  Tumour,  Large 

slightly 

Also  tumours  or  cysts  that 

are  adherent  to  the  spleen 

or  liver. 

1625.  Wandering  Tumours 
Cancer  of  Pylorus  (x) 
Concretions  in  Intestine 
Fatty  Tumour  of  Intestine 

appendix  epiploica 
Floating  Kidney 
Floating  Lobe  of  Liver 

towards  right  ileum 

Floating  Spleen 
Gall-bladder,  Distended 

if  provided  with  a  mesentery 
Impacted  Faeces 
Ovarian  Cyst 

with  long  pedicle 

Phantom  Tumour 
Pyloric  Tumours  (x) 
Tumour,  etc.,  of  Transverse 

Colon 

esp.  when  its  mesentery  is 
long 
Uterine  Fibroid 

pedunculated 

1626  Tumours  of    Abdominal 
Walls 

Abscess 
Cancer 

secondary  growths 
Cysts 

1622-1626 


432 


PALPATION  OF  ABDOMEN 


Tumours   of  Abdominal 
Walls — continued 
Fibroma 
Haematoma 
Herniae,  Minute 

in  linea  alba,  etc. 
Hernia,  Umbilical 


Hernia,  Ventral 

Lipoma 

Lymphadenoma 

secondary  deposits 
Lymphosarcoma 

secondary  deposits 
Nsevus 


1627.  LIVER 

In  infants  it  is  ^V  OI  the  body  weight ;   in  adults  -Jg. 


1628.  Smooth  Enlargement 

Abscess  of  Liver,  Solitary 
Acromegaly 
Actinomycosis 
Amyloid  Liver 

hard  and  veryjlarge 
Angioma,  Cavernous  (x) 
Banti's  Disease 
Bile  Duct,  Obstructed 
Cancer,   Infiltrated 
Cirrhosis,  Hypertrophic,  I. 
Cyanotic  Liver 

u  from  mitral  disease 
Fatty  Liver 

doughy 
Glandular  Fever 
Hsemochromatosis 
Hepatitis,  Acute 
Hydatid  Cyst 

sometimes  huge 
Hypertrophy 
Lymphadenoma 
Leukaemia 
Malaria,  I. 
Mediastinitis 
Obstructed  Bile-ducts 
Pneumonia 
Relapsing  Fever 
Remittent  Fever 
Rickets 
Syphilis,  Congenital 


Trypanosomiasis 

Weil's  Disease 

Yellow  Atrophy,  Ac.  (x) 

***  An  enlarged  fatty  liver  is 
found  in  poisoning  by 
phosphorus,  phloridzin, 
hydrazin,  and  chloroform. 


1629.  Hard  and  Nodular 

Banti's  Disease,  hi. 

Cancer  of  Liver 

shape  altered ;  enlargement 
great ;  nodules  sometimes 
umbilicated 

Cirrhosis  of  Liver,  in. 

nodules    small — not    um- 
bilicated 

Cyst 

Syphilitic  Disease  of  Liver 
nodules  large  and  irregular 

1630.  Circumscribed    Swelling 
on  Liver 

Abscess 
Cancer 
Cholecystitis 
Gumma 
Hydatids 
irregular  prominences 

Riedel's  Lobe 

1626-1630 


PALPATION  OF  ABDOMEN 


433 


1631.  Liver  Depressed 
Angular  Curvature 
Asthma 
Cyphosis  (812) 
Diaphragm,  Paralysis  of 
with  expiration 

Diaphragm,  Tonic  Spasm  of 

Emphysema 

Hsemoglobinuria,    Paroxys- 
mal 

Hepatoptosis 

Hydatids  on  Convexity 

Liver  Enlarged 
gravitation 

Lung,  Cirrhosis  of  Left 
Meso-hepar  (x) 
Pericardial  Effusion  (x) 

left  lobe 
Pleural  Effusion,  Right 
Pneumothorax,  Right  (x) 
Rickets 

Subphrenic  Abscess  (x) 
Tight -lacing 
Tumour 

Liver  Diminished 

(see  Percussion,  1696) 

1632.  Liver  Rotated 

anterior  edge  depressed 

Right  Renal  Tumour 
Tympanites 

1633.  Gall-bladder  Enlarged 

It  is  sometimes  enormous. 

Carcinoma 

Cholecystitis 

Dropsy  of  Gall-bladder 

Empyema  of  Gall-bladder 

Enteric  Fever 

Gallstones 


Mucocele,  Simple 
Pancreas,  Cancer  of  Head  of 
Pancreatitis,  Chronic 
Obstructed      Common      or 
Cystic  Duct 


1631.  Murphy's  Sign 

Pressure  upon  a  tender 
gall-bladder  at  the  end 
of  expiration  causes  a 
catch  in  the  breath. 

Gallstones 


1635.  Spleen  Enlarged 

When  the  enlargement  is 
extreme,  the  organ  may 
dip  into  the  pelvis.  It 
is  not  great  in  acute 
diseases. 

Acromegaly 

Acute  Ascending  Paralysis 
„      Yellow  Atrophy 

Ague,  Acute  and  Chronic 

Amyloid  Disease 
*Banti's  Disease 

Bruhl's  Disease 

Cancer  of  Stomach  (x) 

Cholsemia,  Congenital 

Cirrhosis  of  Liver 

Diphtheria 

Enteric  Fever 

Erysipelas 

Glandular  Fever 

Hepatic  Colic 

Hydatids 

Infarct,  Splenic 

Kala  Azar 

Leukaemia,  Lymphatic 
^Leuksemia,      Spleno-medul- 
lary 

sometimes  nodular 
(       Liver,  Tropical  Congestion  of 

2  f  1631-1635 


**-4 


434 


PALPATION  OF  ABDOMEN 


/T 


Spleen  Enlabged — continued 
Lymphadenoma 
Malta  Fever 
Mediastinitis 
Pancreatitis,  Chronic 
Paratyphoid  Fever 

50  per  cent. 
Pedicle,  Torsion  of 
Pernicious  Anaemia 
Pneumonia  (x) 
Polycythemia,      Splenome- 

galic 
Polymyositis 
Ponos 

Portal  Obstruction 
,,      Thrombosis 
Pseudo-leukaemia  Infantum 
Psittacosis 
Psorospermiasis 
Puerperal  Septicaemia 
Pyaemia 

Relapsing  Fever 
Remittent  Fever 
Rickets  (x) 
Scarlatina  (x) 
Septic  Endocarditis 
Septicaemia 
Status  Lymphaticus 
Still's  Disease 
Syphilis,  Hereditary 

25  per  cent. 
Syphilis,  Secondary 

during  exanthem 
Syphilitic  Liver 
Thrombosis  of  Splenic  Vein 
Trypanosomiasis 
Tuberculosis,  Acute 
Tuberculous  Peritonitis 
Typhus   (prodr.) 
Variola 
Weil's  Disease 


1636.  Spleen  Displaced  (x) 

Ascites 
Emphysema 
Enteroptosis 
Intrathoracic  Tumour 
Meso-spleen 
Meteorism 

Pleural  Effusion,  Left 
Pneumothorax,  Left 
And  in  marked  splenomegaly 

1637.  Lumps    and   Transverse 
Bands 

Tuberculous  Peritonitis 
*#*  The  lumps  are  more  super- 
ficial than  glands  would 
be   and   the   general   re- 
sistance is  doughy. 

1638.  Xiphoid  Fremitus 

A  feeling  like  crepitation 
communicated  to  the 
hand  when  placed  over 
the  xiphoid  cartilage. 

Peritonitis 

1639.  Enlarged   Mesenteric   or 
Lumbar  Glands 

The  mesenteric  glands 
receive  the  lymphatics  of 
the  small  intestine  ;  the 
lumbar  glands,  those  of 
the  pelvis  and  testes, 
and  some  of  those  of  the 
viscera  and  lower  ex- 
tremities. 

Amyloid  Disease 
Cancer  of  Intestine 

„        of  Kidney 

„        of  Testis 
Dysentery 
Enteric  Fever 
Glandular  Fever 
Peritonitis 
Tabes  mesenterica 
Tubercle 

1635-1639 


RECTAL  EXAMINATION 


435 


RECTAL  EXAMINATION 


1640.  Rectal     Examination 

The  index  finger,  inserted 
well  oiled,  should  follow 
with  a  screwlike  move- 
ment the  axis  of  the 
rectum,  viz.  first  forward, 
then  along  the  curve  of 
the  sacrum,  and  lastly 
to  the  patient's  left.  The 
knee-elbow  position  has 
many  advantages  both 
for  digital  and  specular 
examination.  Examina- 
tion may  reveal : — 

Abscess,  Submucous 
smooth  and  very  tender 

Ballooning 
Calculus,  Ureteral 

„  Vesical 

Carcinoma 
Dysentery 
Fistula 
Foreign  Body 
Haemorrhoids 
Glands,  Enlarged  Sacral 
Intussusception    (x) 
Invagination 
Malformations 
Ovarian  Cyst 
Pelvic  Growths,  etc. 
Polypi 


Prostatic  disease 

Pyosalpinx 

Sigmoid  Prolapse 

Stricture,  Fibrous 

Ulceration 

Ureters,  Tuberculous 

Uterus,  Prolapsed 

,,        Retroverted 
Vesiculitis 

c*  In  nervous  diseases  the 
tonicity  of  the  sphincter 
may  be  gauged  by  its 
grip  of  the  finger. 


1641.  Balloning  of  Rectum 

It  occurs  physiologically 
when  the  trunk  is  in- 
verted. 

Colon,  Obstruction  of 

But  it  is  not  uncommonly 
found  where  there  is  no 
obstruction.  In  some  of 
these  cases  it  may  be  due 
to  intestinal  paresis. 


1642.  Reder  s  Sign 

A  tender  spot  on  the  right 
side,  above  O'Beirne's 
Valve. 


Appendicitis 


2  p  2 


1640-1642 


436 


UTERINE  EXAMINATION 


1643.  UTERINE     EXAMINATION 

Bi-manual  examination  gives  the  best  results.  The  patient 
should  lie  on  her  back  with  the  knees  a  little  drawn  up.  While 
the  left  forefinger  explores  the  parts  from  within,  firm  and  steady- 
pressure  is  made  on  the  abdomen  with  the  flat  of  the  right  hand, 
the  pressure  increasing  slightly  with  each  inspiration.  The  uterus, 
ovaries,  fallopian  tubes,  and  broad  ligaments  should  all  be  examined. 
Recto-vaginal  exploration  may  be  necessary  in  some  cases. 


1644.  Cervix  Changes 
Anteflexion 

high ;      os    looks    down- 
wards and  forwards 

Anteversion 

this  is  now  recognised  to  be 
the  normal  position  of 
the  organ 

Atrophy  of  Uterus 

small 

Cancer 

hard ;  os  enlarged  and 
irregular,  with  everted 
lips 

Cancer  of  Body 
os  sometimes  dilated 

Cervical  Catarrh 

puffy,  large,  and  velvety 
in  nullipara  ;  nodular  in 
multipara 

Endometritis,  Acute 

hot,  swollen,  and  puffy ; 
os  dilated  and  velvety 

Endometritis,  Chronic 

normal  or  catarrhal 
Hysteria 

insensitive 
Metritis,  Acute 

swollen  and  hot 
Metritis,  Chronic 

hard      1 


Ovarian  Cyst 

displaced   upwards   and   to 
opposite  side 

Pregnancy 

soft     at     first,     obliterated 
later 

Retro-flexion  and  -version 

low,    with    os    looking   for- 
wards 

Subinvolution 
soft 

1645.  Fullness     of    Douglas's 
Pouch 

Ascites 

Collapsed  Intestine 

Extra-Uterine  Gestation 

rupture 
Hsematocele,  Pelvic 
Hydatids 

Ovarian  Cyst,  Small 
Post- vaginal  Enterocele 
Retroflexion 
Retroversion 

1646.  Central  Swellings 

Anteflexion 
hard  mass  in  anterior  fornix 

Fibroid,  External 
Peritonitis 
thickening  of  fornices 
1643-1646 


UTERINE  EXAMINATION 


437 


Central  Swellings — con- 
tinued 
Sarcoma 

friable  ;    springs  from  body 
of  uterus 

1647.  Lateral  Tumours 

Abscess,  Pelvic 
Cancer  of  Ovary 

u  secondary 
Cellulitis,  Pelvic 
Ectopic  Gestation 
Fibrocystic  Ovary 
Fibroma  of  Ovary 
Haematoma,  Pelvic 
Hematosalpinx 
Hydrosalpinx 
Oophoritis 
Ovarian  Cyst 
Parovarian  Cyst 
Pyosalpinx 
Sarcoma 

1648.  Uterus  Fixed,  or  Painful 
on  Movement 

Adhesions 

Cancer  of  Body  of  Uterus 
Endometritis,  Acute 
Metritis,  Acute 
Ovarian  Tumours 

uterus  high 
Peritonitis,  Pelvic 
Salpingitis 

1649.  Uterus  Enlarged 
Cancer  of  Body 
Elongated  Cervix 
Endometritis 

esp.  septic 
Fibroid 
internal    or    interstitial 


Hypertrophy 
Metritis,  Chronic 
Polypus 
Pregnancy 
Subinvolution 

1650.  Sound         Measurement 

Diminished 

Normally  2|".  The  sound 
must  not  be  inserted 
until  pregnancy  has  been 
excluded.  It  is  now 
rarely  used. 

Adhesions 

Arrested  Development 
Inversion,  Partial 
Senile  Atrophy 
Superinvolution 
Tumour  of  Fundus 

apparent 
Uterus,  Hypoplasia  of 

1651.  Pozzi's  Syndrome 

Leucorrhoea  and  backache 
without  uterine  enlarge- 
ment. 

Endometritis 

1652.  Ballottement 

When  a  push  is  given  to 
the  uterus  by  the  finger 
in  the  vagina  the  organ 
will  rise  and  fall  again. 

Pregnancy 
fourth  to  eighth  month 

1653.  Ahlfeld's  Sign 

Irregular  tetanic  contrac- 
tions affecting  localised 
areas  in  the  uterus. 

Pregnancy 

after  third  month 

1646-1653 


438 


UTERINE  EXAMINATION 


1654.  Hegar's  Sign 

A    boggy    zone    on    lower 
third  of   body  of  uterus. 

Pregnancy 

first  three  months,  whether 
uterine  or  ectopic 


1655.  Reusner's  Sign 

Increased  arterial  pulsation 
in  Douglas's  Pouch. 

Pregnancy 

from  fourth  week 


1656.  Age  of  Foetus. — The  foetus  at  the  end  of  the  second 
month  should  measure  1£  inch  ;  third  month,  2| ;  fourth  month, 
5 ;  fifth  month,  8  ;  sixth  month,  12  ;  seventh  month,  14  ; 
eighth  month,  16  ;  ninth  month,  20. 


1654-1656 


PART  IV 

PERCUSSION 

Contractions  :  u,  usually  ;  x,  exceptionally  ;   *,  the  most  probable 
diseases  ;   i,  First  stage  ;   n,  Second  stage  ;   m,  Final  stage. 

1657. — Percussion. — Deep  percussion  is  best  effected  by  using 
two  fingers  for  a  plessor  ;  superficial,  by  using  the  middle  finger 
only.  The  finger  struck  should  be  pressed  so  firmly  to  the 
patient's  flesh  as  to  be  practically  incorporated  with  it  ;  this  has 
the  advantage  over  a  pleximeter  that  the  feeling  of  resistance 
can  be  gauged.  The  shoulder  and  elbow  joints  should  be  fixed, 
and  the  necessary  motion  be  made  exclusively  at  the  wrist  joint. 
Two  fingers  flexed  so  that  their  ends  are  in  the  same  plane  serve 
as  the  plessor  ;  they  should  remain  only  momentarily  in  contact 
with  the  pleximeter  finger.  Three  or  four  blows  should  suffice  ; 
with  more  than  that,  the  appreciation  of  sound  is  apt  to  lose  its 
acuteness.  Increased  tension  within  the  chest  raises  the  pitch 
of  the  percussion  note.  In  examining  the  apex  for  early  phthisis 
the  patient  should  He  on  his  back  with  the  muscles  relaxed. 
Tested  by  the  spring  balance,  I  find  that  superficial  percussion 
in  my  own  case  is  equal  to  two  ounces,  and  deep  or  heavy  percus- 
sion to  ten  ounces.  Students  might  with  advantage  practize 
with  a  balance,  so  as  to  acquire  uniformity  of  stroke. 

1658.  Heart  Dullness. — Superficial  cardiac  dullness  represents 
the  small  area  normally  uncovered  by  lung.  It  extends  from  the 
left  edge  of  the  sternum  and  from  the  fourth  left  rib  downwards 
to  the  heart's  apex.  The  deep  cardiac  dullness  is  bounded  by  the 
right  edge  of  the  sternum,  the  third  left  rib,  and  a  point  one  inch 
to  the  left  of  the  heart's  impulse.  With  very  heavy  percussion 
it  may  extend  to  a  finger's  breadth  beyond  the  sternum.     The 

1657-1658 


440  PERCUSSION 

area  of  dullness  is  usually  larger  in  the  upright  than  in  the 
recumbent  posture. 

1659.  Liver  Dullness. — This  should  not  extend  below  the 
edge  of  the  ribs.  Its  upper  margin  should  reach  the  fourth  rib 
in  front,  the  seventh  rib  at  the  side,  and  the  ninth  or  tenth  rib 
behind,  on  heavy  percussion.  Percussion  of  the  liver  below 
the  ribs  is  often  vitiated  by  conducted  resonance  ;  to  the  left 
of  the  sternum,  the  liver  dullness  is  continuous  with  that  of  the 
heart. 

1660.  Splenic  Dullness. — A  dullish  note  in  the  mid-axillary 
line  opposite  the  ninth,  tenth,  and  eleventh  ribs  ;  but  palpation 
is  the  best  for  this  organ. 

1661.  Cracked-pot  Sound. — To  bring  this  out,  the  patient 
should  open  his  mouth  and  turn  his  head  away,  when  the  part 
is  percussed. 

1662.  Coin  Sound. — The  physician  listens  at  the  back  while 
the  nurse,  placing  one  coin  flat  on  the  chest  percusses  it  with  the 
edge  of  another  coin.  A  sound  like  that  of  a  hammer  on  an  anvil 
will  be  heard. 


1658-1662 


PERCUSSION 


441 


1663.  CHEST  AND  BACK 


For  normal  chest  resonance  see  Fig.  13. 
everywhere,  though  less  so  over  the  scapulae. 


The  back  is  resonant 


1664.   ABNORMAL   DULLNESS 


Abscess  of  Lung 
Abscess,  Subphrenic 

mammary  or  mid-axillary 
line 

Acromegaly 

over  manubrium  (Erb's 
Symptom) 

Actinomycosis,  Pulmonary 

base  or  axilla 

Aneurysm  of  Aorta 

over,  or  at  one  side  of 
manubrium 

Aneurysm     of     Descending 

Aorta 

left  interscapular  and  supra- 
spinous regions 

Aorta,  Dilated 

manubrium 

Aortitis 

manubrium,  right  second 
space  and  third  cartilage 

Auricle,  Enlarged  Left 

left  interscapular  region 

Bronchial  Glands,  Enlarged 

right  interscapular  region 
opposite  6,  7,  and  8th 
spines 

Bronchiectasis 

where  surrounded  by  con- 
densed lung-tissue 

Cancer  of  Lung,  Extensive 

„        of  Pleura 

Cirrhosis  of  Lung 

all  one  side ;  wooden ; 
high-pitched 


Collapse  of  Lungs 

a  strip  each  side  of  spine. 

Congestion  of  Lungs,  Hypo- 
static 
bases  of  lungs 

Empyema 

Encysted  Empyema 

Enteric  Fever 

dullness  of  the  right  base 
is  said  to  occur  in  80  per 
cent,  of  cases  (Lesieur) 

Enteroptosis 

loss  of  tympanitic  note  in 
Traube's  space 

Faecal  Accumulation 

Traube's  space 
Gangrene  of  Lung 

before  softening 

Hsemothorax 

Hydatids  of  Liver 
convexity  upwards 

Hydatids   of  Lung,    Super- 
ficial 
in  lower  axilla 

Hydropneumothorax 
shifting  with  position 

Hydrothorax 

fluid  gravitates  with  change 
of  position 

Lobular  Pneumonia  (x) 

only  when  several  areas 
have  coalesced 

1663-1664 


442 


PERCUSSION 


Abnormal  Dullness  —  con- 
tinued 

Mediastinal       Abscess       or 
Growth 
5th  and  6th  dorsal  spines 

(Edema  of  Lungs 

both  bases  ;    but  unequally 

Pericardial  Effusion 

triangular  with  apex  above, 
also  in  left  interscapular 
region 

Phthisis,  I. 

suprascapular,  supra-clavi- 
cular, infraclavicular 

In  early  phthisis  there  is  a 
patch  of  dullness  adjoining 
the  sternum  in  the  first 
space ;  another  in  the 
second  space :  a  third, 
on  the  outer  margin  of 
the  infraclavicular  region ; 
a  fourth  between  spiii3 
and  suprascapular  region 
(Dr.  Lees). 

Pleura,  Thickened 

wooden 

Pleurisy  with  Effusion 

The  fluid,  which  is  un- 
affected by  gravitation, 
begins  from  below ;  the 
upper  limit  of  dullness 
being         '  S '  curved 

(Damoiseau's,   Ellis's,    or 
Garland's  '  Line  '). 

Pneumonia,  Acute 

u  right  base 

Pneumonia  Serpens 

healing  in  one  direction, 
while  advancing  in 
another 

Pneumonoconiosis 

esp.  right  apex 
Pneumothorax 

when  distension  is  extreme 


Pulmonary  Apoplexy 

circumscribed  incomplete 
dullness  ;  usually  in  mam- 
mary or  axillary  region 

Renal  Swellings 

over  lower  ribs  and  upper 
part  of  loins 

Syphilitic  Disease  of  Lungs 

in  patches,  or  with  signs  of 
collapsed  lungs 

Thymus,  Enlarged 

manubrium 
Tuberculosis,  Acute  (x) 
Veronal-poisoning 

patches 
(See  Enlarged   Liver,   1698  ; 

Spleen,  1635  ;   and  Heart, 

1691) 

1665.  Apical  Dullness 

In  addition  to  pulmonary 
tuberculosis,  this  con- 
dition is  found  in  mouth- 
breathers  ('  collapse  in- 
duration'), emphysema 
(relative),  cardiac  cases, 
syphilis,  empyema,  gan- 
grene pneumococcal  infec- 
tions, infarcts,  hydatids, 
catarrh  following  influ- 
enza and  in  healed 
cavities. 

The  right  apex  sometimes 
gives  a  duller  note  from 
the  greater  muscularity 
of  that  side. 

1656.  Traube's  Space,  Dullness 

of 

The  note  normally  is  tym- 
panitic 

*Enteroptosis 
Faecal  Accumulation 
Pleural  Effusion,  Left 
Spleen,  Enlarged  (1635) 
Viscera,  Transposition  of 

1664-1666 


PERCUSSION 


443 


1667.  Bird's  Sign 

A  zone  of  dullness  with 
absence  of  respiratory 
sounds. 

Hydatid  Cyst  of  Lung 


1668.  Rotch's  Sign 

Dullness  at  the  sternal 
border  of  the  fifth  right 
space. 

Auricle,  Enlarged  Right 
Dilatation  of  Heart,  Acute 
Pericardial  Effusion 

1669.  Grocco's  Triangle 

A  narrow-based  triangular 
area  of  dullness  abut- 
ting upon  the  vertebral 
column  and  having  its 
apex  above.  It  disap- 
pears when  the  patient 
lies  on  the  opposite  side. 

Large  Abdominal  Swellings 

♦Pleural  Effusion 

of  opposite  side 

Pregnancy 


1670.  Cracked-pot  Sound 

(Bruit  de  pot  fele) 

Usually  due  to  a  super- 
ficial empty  cavity  that 
communicates  freely  with 
a  bronchial  tube.  It  is 
normal  in  a  crying  infant. 

Bronchiectasis 

Gangrene  of  Lung 

*Phthisis,  ii. 

Pneumonia,  Acute  (x) 

due  to  an  islet  of  relaxed 
lung  tissue  surrounded  by 
hepatisation 

Pneumothorax  (x) 


Pyopneumothorax 
with  wide  fistula 
Relaxed  Lung 

1671.  Sense  of  Resistance 

Diminished  lung  elasticity. 

Cancer  of  Pleura 
Cirrhosis  of  Lung 
Distension  of  Lung,  Extreme 
Emphysema 
Pleura,  Thickened 
Pleural  Effusion 
Pneumonia,  Acute 

moderate 
Pneumothorax,  Extreme 

1672.  Myoidema 

Percussion  produces  a  small 
prominence  where  struck. 

Carcinoma 
Phthisis 

pectoral  muscle 
^Pneumonia,  Acute 

affected  side 
Wasting  Diseases 

1673.  Hyper-resonance  or  Ab- 
normal Resonance 

Actinomycosis 

cavity 
Asthma,  Spasmodic 
Atrophy    or    Shrinking    of 

Liver 

Bronchiectasis 

consolidation  between  the 
dilatation  and  the  surface 

Cavity,  Large  Relaxed 

Cirrhosis  of  Opposite  Lung 

extending  a  little  beyond 
opposite  border  of 
sternum 

1667-1673 


444 


PERCUSSION 


Hyper-resonance  or  Ab- 
normal Resonance — contd. 
Dilatation  of  Stomach 

left  axilla 
Emphysema 
Gangrene  of  Lung 

after  softening 
Kidney,  Congenital  Absence 

of  One 

one  lumbar  region 
Kidney,  Floating 

one  lumbar  region 

Margin   of   Lung   bordering 

on  Consolidation 
(Edema  of  Lungs 

Huchard's        Paradoxical 
Resonance 

Perforation     of     Bowel     or 

Stomach 
Pneumothorax 

all  one  side 
Relaxed  Lung  above  Pleural 

Effusion 

infraclavicular 
Transposition  of  Viscera 

prsecordium 
Tuberculosis,  Acute  Miliary 

patchy 

1674.  Tympanitic     Resonance 
in  Chest 

Colon,     Distended     Trans- 
verse 

Idiopathic      Dilatation      of 
Colon 
both  hypochondria 

Stomach,  Dilatation  of 

left  axilla 

In  Traube's  semilunar  space, 
which  corresponds  on  the 


left  to  the  position  occu- 
pied by  the  liver  on  the 
right,  the  note  is  normally 
tympanitic. 

1675.  Skodaic  Resonance 

High  -  pitched  resonance 
above  large  area  of  dull- 
ness due  to  : — 

Abscess  Hepatic 

,,        Subphrenic 
Cor  Bovinum 
Liver,  Cancer  of 

,,       Gumma  of 

„       Hydatids  of 
Lung,  Compressed 

from  abdominal  pressure 

Mediastinal  Growth 
Pericardial  Effusion 
*Pleural  Effusion 
Pneumonia,  Basal 
Pulmonary  Infarct 
Sarcoma  of  Lung 
Splenomegaly 

1676.  Amphoric  Resonance 

It  sounds  like  tapping  an 
empty  earthenware  jar. 

Cavity,     Large     Superficial 

and  Empty 
Cirrhosis  of  Lung 
Hernia  of  Stomach 

through  diaphragm 

Phthisis 
Pneumothorax 
Subphrenic  Abscess 

1677.  Coin  Sound  (Bruit  d'air- 
ain  or  Signe  du  Sou) 

Diaphragmatic  Hernia 
Distended  Colon  (x) 
Hydropneumothorax 

1673-1677 


PERCUSSION 


445 


Coin  Sound — continued 
Pleural  Effusion 
upper  level  of  fluid 

*  Pneumothorax 
Pyopneumothorax 
Subphrenic  Abscess 

1678.  Thrill  on  Percussion 
Hydatids 

wavy 
Hydropneumothorax 

vibratory 
Pyopneumothorax 


1679.  Lung  Apex,  High 

Emphysema 
bulging  with  inspiration 

1680.  Lung  Apex,  Low 
Cirrhosis  of  Lung 
Collapse  of  Lung 
Phthisis 

an  early  symptom 

1681.  Kellock's  Sign 

Vibration  of  the  ribs  when 
percussed. 

Pleural  Effusion 

(Absent  in  pneumonia. 


1677-1681 


446 


PERCUSSION 


1682.  VARIATIONS  IN  PERCUSSION  NOTE 


1683.  Wintrich's  Sign 

Pitch  higher  on  opening 
the  mouth. 

Cavities 
Pneumothorax 

1684.  Interrupted  Wintrich 

This  term  is  applied  when 
Wintrich's  sign  is  obtained 
in  the  recumbent,  but 
not  in  the  erect  position, 
or  vice  versa. 

Cavity  containing  Fluid 

1685.  William's  Sign 

The  same  as  Wintrich's, 
but  heard  over  apex  of 
lung  and  due  to  con- 
duction from  the  trachea. 

Consolidation  of  Lung 


1686.  Gerhardt's  Sign 

Note  altered  by  change  of 
posture. 

Cavity,  Half-filled 


1687.  Biermer's  Sign 

Note  deeper  when   patient 
sits  up. 

Hydropneumothorax 


1688.  Friedreich's    Percussion 

Sign 

Note  higher  on  deep  inspira- 
tion. 

Cavities 


1682-1688 


CARDIAC  DULLNESS 


447 


CARDIAC    DULLNESS 


Fig.  13. — Diagram  showing  Superficial  Cardiac  Dullness 
(black),  Deep  Cardiac  Dullness  (vertical  lines),  and 
Liver  Dullness  (horizontal  lines) 


1589.  Dullness  Increased  Ver- 
tically 

Abscess,  Subphrenic 
Aortic  Regurgitation 
Cancer  of  Pericardium 

„       of  Pleura 
Cardiac  Aneurysm 
Consolidation  of  Lung  abov  s 

Heart 
Contraction  of  Left  Lung 

or  of  a  vomica  within  it 

Encysted     Empyema     or 
Pleurisy,  near  Heart 

Endocarditis,  Acute 

Fatty  Degeneration  of  Heart 
*Hypertrophy  of  Left  Ven- 
tricle 
esp.  if  excentric 

Hypertrophy  of  Right  Ven- 
tricle 


Myocarditis,  Acute 
Pericardial  Effusion 
Syphilitic  Heart 

1690.  Dullness      Increased 
Transversely 

Aortic  Regurgitation 
to  left 

Dilatation  of  Left  Ventricle 

dullness    to    left    of  nipple 
line 

*Dilatation  of  Right  Auricle 
dullness    in    3rd    and    4th 
right  spaces 
Dilatation    of    Right    Ven- 
tricle 

pyramidal  when  acute 
Endocarditis 
Exophthalmic  Goitre 
transient  dilatation 
Fibroid  Heart 

1689-1690 


448 


CARDIAC  DULLNESS 


Dullness  Increased  Trans- 
versely— con  tinued 

Hypertrophy   of  Left   Ven- 
tricle 

Lordosis  (813) 

Mediastinitis 

Mitral  Regurgitation 
„        Stenosis,  Late 

Pericardial  Effusion 

pyramidal;  base  line 
reaching  sometimes  to 
right  nipple  line  and 
beyond  the  point  of  maxi- 
mum impulse  to  the  left 

Pleural  Effusion 

if  right,  to  left ;  if  left, 
to  right 

Retraction  of  Left  Lung 

1691.  Dullness     Increased 
Equably 

Endocarditis 

High  Diaphragm 

Myocarditis 

Universal  Hypertrophy 


1692.  Dullness  Increased  Irre- 
gularly 

Aneurysm  of  Aorta 
Mediastinal  Tumour 
Patent  Foramen  Ovale 


1693.  Cardiac  Dullness  Dimin- 
ished 

Atrophy  of  Heart 

slightly 

Cancer  of  Stomach  (x) 
Cirrhosis  or  Contraction  of 

Right  Lung 
Emphysema 

Pneumohydropericardium 
Pneumopericardium 
Pneumothorax,  Left 


1694.  Dullness    Undiminished 
by  Inspiration 

Adhesion  of  Pericardium  to 
Pleura 


1690-1694 


PERCUSSION  OF  ABDOMEN 


449 


1695.  PERCUSSION    OF    ABDOMEN 

The   abdomen    is    normally   resonant    everywhere,    apart    from 
organ  contents.     Flicking  with  finger  and  thumb  is  often  useful. 


1696.  Liver    Dullness   Dimin- 
ished or  Absent 

Percussion  should  be  made 
in  the  mid-axillary  line 
with  the  patient  sitting 
up. 

Acute  Yellow  Atrophy 

Cirrhosis  of  Liver,  in. 

Cirrhosis  or  Contraction  of 
Left  Lung 

Diaphragmatic  Hernia  (x) 
rare  on  right  side 

Dilatation    of    Colon,    Idio- 
pathic 

Distended  Colon 

Emphysema 

Hepatoptosis 
apparent  only 

Pneumoperitoneum 

from  perforation  of  bowel 
or  stomach  (Clark's  Sign). 

Pneumothorax,  Right 

Transposition  of  Viscera 

Tympanites 

1697.  Liver    Dullness    Altered 

Constricted  Right  Lobe 

tight  lacing 
Riedel's  Lobe 
Tumours  of  Liver 

1698.  Liver  Dullness  Increased 

Abscess  of  Liver 
Acromegaly 
Actinomycosis 
Amyloid 


Cancer  of  Liver 
,,        of  Omentum 
„        of  Pancreas 
,,        of  Right  Kidney 
,,        of  Stomach 

Cirrhosis,  Hypertrophic 

Cyanotic  Liver 

Faecal  Accumulation 

Fatty  Degeneration  of  Liver 

Glandular  Fever 

Gummata  of  Liver 

Hydatids 
vibratory 

Hypertrophy,  Simple 

Leukaemia 

Liver,  Tropical  Congestion  of 

Lymphadenoma 

Mediastinal  Tumours 

Obstructed  Bile-Ducts 

Pericardial  Effus"on,  Exten- 
sive 

Pleural  Effusion,  Right 

Weil's  Disease 

1659.  Liver  Raised 

Abdominal  Tumours 
Abscess,  Hepatic 
apparent4  only 

Ascites 

Cirrhosis,     Contraction,     or 
Collapse    of    Right    Lung 
Hydatids  of  Liver 
Ovarian  Cyst 
Paralysis  of  Diaphragm 

with  inspiration 
Tympanites 
a  1695-1699 


450 


PERCUSSION  OF  ABDOMEN 


Liver    Depressed    (See    Palpa- 
tion, 1631) 

Spleen    Enlarged    (See    Palpa- 
tion, 1635) 

1700.  Tympanites  or  Meteorism 

Dysentery 

Enteric  Fever 

Hysteria 

Ileus 

Intestinal  Catarrh  (x) 

Intestinal      Obstruction, 
Acute 

Peritonitis,  Acute 

Pneumoperitonaeum 

from  perforation  —  owing 
to  appendicitis  or  to 
gastric,  dysenteric,  syphi- 
litic, typhoid,  or  tuber- 
culous ulcer.  Rarely  from 
Bacillus  aerogenes 

Puerperal  Septicaemia 
Spinal  Cord,  Chronic  Disease 

of 
Tabes  mesenterica 
Typhic  State  (62) 

1701.  Gunzberg's  Sign 

A  resonant  area  between 
the  gall  bladder  and  the 
pylorus  with  localised 
borborygmi. 

Duodenal  Ulcer 

1702.  Partial  Abdominal  Dull- 
ness 

Abdominal  Aneurysm 
Abscess,  Appendicular 

,.,         Subphrenic 
Ascites 

lowest  part  or  encysted 
Cancer  of  Kidney 

,,       of  Pancreas 
Choleperitonaeum 


Colloid  Omentum 

Cysts  of  Mesentery  or  Omen- 
tum 

Distended  Bladder 

Enlarged  Liver  (See  Palpa- 
tion, 1627) 

Enlarged  Spleen  (see  Palpa- 
tion, 1635) 

Faecal  Accumulation 
record  weight,  47  lbs. 

Gall-bladder,  Distended 

Haematoperitonaeum 

Hydatids 

Intestinal  Obstruction,  Seat 
of 

Omentum,  Thickened 

Peritonitis,  Loculated 
,,  Malignant 

Pyoperitonaeum 

Stomach,  Diffuse  Cancer  or 
Cirrhosis  of 

Thrombosis,  Portal 
„  Splenic 

Tumours  (1615) 
*#*  The    note    over    intestinal 
cancer  is  usually  resonant. 

1703.  Cracked-pot  Sound 

Intestinal  Occlusion 
Retrocaecal  Abscess 

1704.  Ascites 

When  the  patient  sits  up, 
the  upper  limit  of  dullness 
is  concave  and  the  flanks 
bulge.  The  dullness  shifts 
with  position,  being 
always  most  marked  at 
the  lowest  point. 

Anaemia  (x) 
Anarsarca  (335) 
Aneurysm  (x) 
Appendicitis,  I. 
quantity  small 

1699-1704 


PERCUSSION  OF  ABDOMEN 


451 


Ascites — continued 

Banti's  Disease 

*Cancer  of  Liver 

„        Peritonaeum 
♦Cirrhosis  of  Liver,  in. 

„       Hyper- 
trophic (x) 
Cyanotic  Liver 
Glands,  Enlarged  Portal 
Hydatids,  Peritonseal 
Kidney,    Cirrhosis    of,    in. 
Lung,  Fibroid 
Mediastinal  Growth 
Mediastinitis,  Chrome 
Mitral  Disease 
Myocardial  Affections  (x) 
Ovarian  Cyst,  Rupture  of 
Pancreatitis  (x) 
Pericardial  Pseudo-cirrhosis 
Perihepatitis 

quickly  refilling 
Peritonitis,  Acute  (x) 
,,  Malignant 

♦Peritonitis,  Tuberculous 
Portal  Obstruction 
Syphilitic  Liver  (x) 
Thoracic   Duct,    Obstructed 
♦Thrombosis,  Portal 
onset  sudden 
Tubal  Pregnancy  (Rupture) 
Tumours,  Abdominal 
from  pressure  on  veins 

1705.  Fluid  Test 

The  stomach,  when  partially 
filled  with  liquid,  yields 
to  percussion  a  dull  area 
one  inch  above  the  um- 
bilicus. 

In  Dilatation  of  the 
Stomach,  this  dull  area 
is  at  or  below  the 
umbilicus. 

2    G 


1706.  Gaseous    Test   for    Sto- 
mach 

Artificial  distension  of  the 
stomach  is  produced  by 
the  patient  taking  suc- 
cessively a  teaspoonful  of 
bicarbonate  of  soda  and 
the  same  quantity  of 
tartaric  acid  upon  an 
empty  stomach.  A  glass 
of  soda-water  does  almost 
as  well.  The  colon  may 
be  advantageously  dis- 
tended with  fluid  first. 

Resonance    over     previously 

Dull  Area 
Dilated  Stomach 
Pancreatic  Enlargement 

1707.  Gaseous  Test  for  Colon 

The  acid  and  alkali 
are  introduced  into 
the  previously  emptied 
rectum  ;  or  air  may  be 
injected  with  a  long- 
tubed  Higginson's  Syringe. 

Resonance  over  'previously 
Dull  Area 

Renal  Tumours  or  Cysts, 
Hydronephrosis,  Pyo- 
nephrosis, '  Lobstein's 
Cancer,'  and  all  post- 
peritonseal  swellings 

Ewald  distends  the  colon 
before  palpating  for  Ap- 
pendicitis larvata. 


1704-1707 


452 


MISCELLANEOUS   PERCUSSION 


1708.  MISCELLANEOUS  PERCUSSION 


1709.  Percussion  of  Head 
Heavy    percussion    on    the 

vertex    elicits   tenderness 
in  the  cervical  vertebrae. 

Caries 

Rheumatoid  Arthritis 

A  '  cracked  pot '  sound  is 
sometimes  heard  over  the 
area  of  a  fractured  skull. 

1710.  Macewen's  Sign 

Increased  resonance  on  com- 
bined percussion  and  aus- 
cultation of  skull. 

Cerebral  Abscess 
Distended  Ventricle 
Gross  Cerebral  Lesion 

1711.  Auscultatory    Percus- 
sion 

The  chest  piece  should  be 
held  in  position  by  the 
patient  or  nurse.  Percus- 
sion is  then  made  over 
the  supposed  boundary 
of  an  organ.  The  differ- 
ence   in    note     is     more 


marked  than  in  simple 
percussion.  It  is  em- 
ployed for  determining 
the  boundaries  of  the 
solid  viscera  or  of  a  dila- 
ted stomach — the  stetho- 
scope being  applied  to  the 
centre.  Some  observers 
prefer  a  scratching  move- 
ment of  one  finger  to 
percussion.  A  hydatid 
cyst  is  said  to  yield  the 
'  sonorous  booming  of 
Santini.' 

Percussion  of  Spine  (see  Spinal 
Tenderness,  156) 


1712.  PERCUSSION 
LIMBS 


OF 


1713.  Trochanteric 

Pain  in  knee  on  percussion 
over  great  trochanter. 

Hip  Disease 

1714.  Patellar  Tap 

Effusion  into  Knee  Joint 
'  double  knock  ' 


1708-i714 


PART  V 

AUSCULTATION 

Contractions  :  u,  usually  ;  x,  exceptionally  ;   *,  the  most  probable 
diseases  ;   I,  First  stage  ;   n,  Second  stage  ;   in,  Final  stage. 

1715.  The  chest  is  normally  the  seat  of  certain  circulatory 
and  respiratory  sounds,  and  auscultation  enables  us  to  appreciate 
their  variations.  Lung  sounds  are  either  direct  or  conducted. 
Thus  bronchophony  is  direct  if  due  to  a  dilated  bronchus  under 
the  stethoscope  ;  but  indirect  or  conducted  if  due  to  trans- 
mission from  a  normal  bronchus  through  the  intermediary  of  a 
good  conductor  of  sound  such  as  consolidated  lung.  Internal 
direct  sounds  are  due  to  the  movement  of  air  or  air  and  mucus  in 
the  tubes  or  air-cells,  and  are  usually  heard  best  on  inspiration  ; 
external  direct  sounds  are  due  to  roughness  of  the  pleura,  and  are 
heard  with  inspiration  and  expiration.  Coughing  will  silence  or 
lessen  internal  mucous  sounds,  but  has  no  effect  upon  external 
or  friction  sounds.  Fluid  is  said  in  books  on  physics  to  be  a 
good  conductor,  but  it  is  very  rarely  so  in  the  chest. 

In  the  auscultation  of  the  back,  a  towel  may  replace  the 
stethoscope,  the  patient  being  told  to  lean  forward  and  cross  his 
arms.  In  order  to  get  a  patient  to  breathe  deeply  enough,  he 
should  be  made  to  hold  his  breath  ;  his  after-dyspncea  may  then 
be  taken  advantage  of  for  the  auscultation  of  the  lungs.  An 
adventitious  crackling  is  sometimes  heard  with  the  double 
stethoscope,  particularly  when  the  chest  is  hairy,  and  may  be 
avoided  by  wetting  the  skin.  The  phonendoscope  is  chiefly 
of  use  for  localising  murmurs  and  circumscribed  friction  sounds  ; 
but  it  does  not  conduct  high-pitched  sounds  very  well. 


1715 


454 


AUSCULTATION  OF  LUNGS 


AUSCULTATION     OF    THE    LUNGS 


1716.  Puerile  Breathing 

As  in  infants.  It  is  due 
to  over  -  functioning  of 
one,  or  of  part  of  one, 
lung. 

Cirrhosis  of  Opposite  Lung 
Collapse  of  Opposite  Lung 
Compression     of     Opposite 

Lung 
Pleural  Effusion 

in  infraclavicular  region 

1717.  Wavy      or      Saccadee 
Breathing 

'  Of  little  value  '  (Dr.  Gee). 
Bronchial  Catarrh 
Hypertrophy  of  Heart 
Nervousness 

Patchy  Pleuritic  Adhesions 
Phthisis,  i. 

'  Cog-wheel '  inspiration. 
It    is    also    present    when 

chest      movements      are 

painful. 

1718.  Weak  or  Absent  Breath- 
ing Sounds 

Due  to  weak  expansion,  to 
fatty,  oedematous,  or 
painful  chest  walls,  or 
to  occluded  bronchus, 
blocked  alveoli,  or  inter- 
posed fluid. 

Aneurysm 

Asthma,  Spasmodic 
Bronchial     Secretion,     Re- 
tained 
Bronchitis,  Plastic 
Cancer  of  Lung 


Cirrhosis  of  Lung 

in  parts 
Collapse  of  Lungs  (x) 
Congestion  of  Lungs  (x) 
Diaphragmatic  Hernia 
Diaphragmatic  Pleurisy 

at  base 

Emphysema 

Encysted  Pleurisy  or  Pneu- 
mothorax 

Foreign  Body  in  Bronchus 

Gangrene  of  Lung 

Hydatids  of  Lung 

Hydropneumothorax 

Mediastinal  Tumour 

(Edema  of  Lungs 

Phthisis,  i. 

Pleura,  Adherent  or  Thick- 
ened 

Pleura,  Cancer  of 
*Pleural  Effusion 

Pneumothorax 

Pyopneumothorax 

Tympanites 

To  be  of  value  this  symptom 
must,  except  in  the  case 
of  emphysema,  co-exist 
with  normal  breathing 
elsewhere. 

When  fluid  or  air  separates 
the  lung  from  the  chest 
wall,  the  breathing  sounds 
are  '  distant'  or  inaudible. 


1719.  Aufrecht's  Sign 

Short  and  weak  breathing 
over  trachea. 

Tracheal  Stenosis 

1716-1719 


AUSCULTATION  OF  LUNGS 


455 


1720.  Prolonged  Expiration 

Generally  due  to  lessened 
elasticity  of  the  lungs. 

In  health,  the  duration  of 
inspiration  as  compared 
to  expiration  is  as  5  to  6. 

Asthma,  Spasmodic 

Bronchiectasis 

Bronchitis,  Plastic 

Consolidation,   Commencing 
*Emphysema 

Hay  Asthma 

Hydatids  of  Lung 

Laryngitis,  Acute 

Obstructed  Bronchus 
*Phthisis,  i. 

Phthisis 
healed  cavity 

1721.  Bronchial     or     Tubular 
Breathing 

This  is  normal  when  the 
bronchi  are  near  the 
surface,  as  at  the  upper 
part  of  the  sternum  and 
between  the  spines  of 
the  scapulae :  abnormal 
when  a  solid  is  interposed 
between  the  surface  and 
a  distant  bronchus  ;  and 
when  a  bronchiole  is 
dilated.  Its  pitch  is  low 
in  direct  proportion  to 
the  size  of  the  bronchus. 
To  elicit  it,  the  patient 
must  take  a  full  deep 
breath. 

Actinomycosis 

Aneurysm 

Bronchial  Glands,  Enlarged 

Bronchiectasis 

Bronchopneumonia 

when  extensive 
Cancer  of  Lung 


Cirrhosis  of  Lung 
Collapse  of  Lung 
Compression  of  Lung 
Empyema  (x) 
Gangrene  of  Lung 
Mediastinal  Tumour 
(Edema  of  Lungs 
Phthisis,  ii. 
Pleural  Effusion  in  Children 

and,  if  in  thin  layer,  very 
extensive,  or  distant,  in 
adults 

Pleurisy  (x) 
adherent  bands 

*Pneumonia,  Acute,  n. 

whiffing 

Pulmonary  Apoplexy 
Syphilitic  Lung 
Vomica  communicating  with 
a  Bronchus 

***  Where  some  healthy  lung 
is  interposed,  as  in  central 
pneumonia,  the  breathing 
may  be  broncho -vesicular 
or    '  Indeterminate.' 


1722,  Cavernous  Breathing 

Usually  due  to  an   empty, 
patent  cavity. 

Abscess  of  Lung 
Bronchiectasis 
Cancer  of  Lung 
broken  down 

Cirrhosis  of  Lung 
Gangrene  of  Lung 
*Phthisis,  m. 
Pleurisy  (x) 

Pneumothorax,   Loculated 
Syphilitic  Lung,  in. 

1720-1722 


456 


AUSCULTATION  OF  LUNGS 


1723.  Amphoric  Breathing 

Usually  due  to  a  smooth 
walled  superficial  cavity 
of  at  least  moderate  size. 
It  resembles  the  sound 
made  by  blowing  across 
the  mouth  of  a  jar. 

Abscess,  Subphrenic  Gaseous 
Bronchiectasis 
Gangrene   of  Lung,   III. 
*Phthisis,  III. 
Pneumothorax,  or  Pyopneu- 
mothorax 


communicating 
bronchus 


with 


Coin  Sound  (see  1677) 

1724.  Post-Tussive  Suction  or 
India-rubber  Ball  Sound 

Heard  during  the  respira- 
tory pause,  following  a 
cough.  It  sounds  like  a 
rubber  ball  expanding 
after  compression. 

Cavity 

with  rather  elastic  walls 

1725.  Gurgling 

Caused  by  a  churning  of 
air  and  viscid  fluid. 

Abscess  of  Lung 

Actinomycosis 

Bronchiectasis 

Caseous  Softening 

*  Cavity,  Large 

Collapse  of  Lung 

around  a  large  bronchus 

Gangrene  of  Lung,  in. 
Hydatids  of  Lung 
after  rupture 


Phthisis,  in. 

***  The  sound  is  sometimes 
conveyed  from  the  oeso- 
phagus by  consolidated 
lung  tissue  (1787). 


1726.  Rhonchus  or  Dry  Sonor- 
ous Rale 

Due  to  partial  occlusion  of 
the  larger  tubes,  usually 
by  tough  mucus ;  so 
that  the  air  is  drawn 
as  in  the  glottis,  through 
a  slit  with  vibrating 
edges. 

Ague  (warm  stage) 
*Asthma,  Spasmodic 

Bronchial  Catarrh 
*Bronchitis,  Acute  or  Chronic 
first  dry,  afterwards  moist 

Bronchitis,  Plastic 

Bronchorrhcea 

Bronchus,    Partially    Ob- 
structed 

Collapse  of  Lung  (x) 
*Emphysema 

Enteric  Fever 

Hay  Asthma 

Hooping  Cough 

Influenza 
'  sticky  ' 

Iodism 
Measles 

Mediastinal  Tumour 
Mitral  Disease 
Pernicious  Intermittent 
Phthisis,  ii. 

conducted  from  a  bronchus 

Psittacosis 
Relapsing  Fever  (x) 
Remittent  Fever 

1723-1726 


AUSCULTATION  OF  LUNGS 


457 


Rhonchus  or  Dry  Sonorous 
Rale — continued 
Rickets 

Tuberculosis,  Acute 
Tympanites 
Variola 

1727.  Sibilus  or    Dry    Sibilant 

Rale 

Usually  associated  with 
rhonchus  and  engendered 
in  the  same  way,  though 
in  the  smaller  tubes. 

Aneurysm  or  Tumour 
pressing  on  bronchus 
*Asthma,  Spasmodic 
Bronchial  Catarrh 

*  Bronchitis,  Acute  or  Chronic 

*  Bronchitis,  Plastic 
Broncho-pneumonia 
Enteric  Fever 
Hay  Asthma 
Hooping  Cough 
Hypertrophy  of  Heart 
Influenza 

*Measles 
Variola 

1728.  Dry  Crackle 

'  Bruit  de  Drapeau  ' 
A    sound    resembling    the 
flapping  of  a  flag. 

Emphysema,  Interlobular 

„  Vesicular 

Tuberculosis   (softening) 
breaking  down  of  tubercles 

1729.  Metallic  Tinkling 

This  is  best  brought  out  by 
sudden  change  of  posture. 
It  sounds  like  a  drop  of 
water  falling  into  a  cistern 
and  is  due  to  a  similar 
cause. 


Diaphragmatic  Hernia 
Phthisis,  in. 
Pneumothorax,  Patent 

1730.  Water  Whistle  Noise 

Pulmonary  Fistula 


1731.  Moist     Crepitation       or 

Crepitant  Rale 

Crepitation  is  divided  into 
fine,  medium,  and  coarse, 
according  to  the  size  of 
the  tube  in  which  it 
originates.  Coarse  and 
medium  crepitation  are 
due  to  the  bursting  of 
bubbles  ;  but  fine  crepita- 
tion arises  from  the 
sticking  together  and 
unsticking  of  adjacent 
surfaces.  The  subcrepi- 
tant  rale  which  is  heard 
towards  the  end  of  in- 
spiration can  be  well 
imitated  by  rolling  be- 
tween finger  and  thumb 
a  wisp  of  hair  near  the 
observer's  ear. 

Broncho  -pneumonia 

subcrepitant  rales  with  in- 
spiration and  expiration — 
audible  in  patches 

Cerebro- spinal  Meningitis 

Cirrhosis  of  Lung 
coarse — metallic 

Collapse  of  Lung 
fine 

Compressed  Lung 

Congestion  of  Lungs,  Hypo- 
static 

Empyema  (x) 

Gangrene  of  Lung,  I. 

Hooping  .Cough,  i. 

1726-1731 


458 


AUSCULTATION  OF  LUNGS 


Moist  Crepitation  or  Cre- 
pitant Rale — continued, 
Imperfect  Expansion  of  air- 
cells  in  bedridden  patients 

removed  by  a  few  deep 
inspirations 

(Edema  of  Lungs 
(Edema  of  Pleura 
fine 

Phthisis,  i.  and  n. 

apex  ;  heard  with  inspira- 
tion and  expiration 

Phthisis,  in. 

coarse  and  clicking 

Pneumonia,  Acute 

i,  fine,  dry,  inspiratory ; 
m,  subcrepitant  rale — 
'  crepitatio    redux  ' 

Pulmonary  Apoplexy 
Tuberculosis,  Acute 
fine 

*Tuberculous  Pleurisy 

Tiirgensen's  sign ' 

Woillez'  Disease 

+*  Deglutition  rales  may  be 
conducted  to  the  apex 
of  a  lung.  They  cease 
if  the  patient  keeps  his 
mouth  open,  because  this 
prevents  him  from  swal- 
lowing.    See  1787. 


732.  VOCAL  RESONANCE 

The  patient  should  be  made 
to  cough  or  speak  loudly 
while  the  physician's  ear 
or  stethoscope  is  at  the 
chest. 

Increased 

(As  in  Bronchophony,  1735) 


1733.  Diminished  or  Absent 

Bronchus,  Obstructed 
Collapse  of  Lung 
Emphysema 
Empyema 
(Edema  of  Pleura 
*Pleural  Effusion 
Pneumothorax 
Thickened  Pleura 

1734.  ^gophony 

A  sound  resembling  that 
of  a  bleating  goat — rare. 

Pleural  Effusion 

either  in  thin  layer  or  at 
upper  limit  of  thicker 
layer.  Heard  best  under 
the  scapula ;  probably 
due  to  collapsed  bronchial 
tubes. 

Pneumonia  (x) 

1735.  Bronchophony 

An  inarticulate  sound  heard 
normally  over  the  upper 
dorsal  spinous  processes 
and  under  the  right 
clavicle  near  the  sternum 
— especially  in  women. 
It  is  generally  associated 
with  bronchial  breathing. 

Bronchial  Glands,  Enlarged 
over  upper  dorsal  spines 

Bronchiectasis 

Cancer  of  Lung 

Cirrhosis  of  Lung 

Emphysema,  Marked 

Phthisis,  ii. 

Pleural  Effusion 
if  in  thin  la}Ter 

*Pneumonia,  Acute 
sometimes    '  sniffing ' 
Pulmonary  Apoplexy 
Syphilitic  Lung 
Tuberculosis 

1731-1735 


AUSCULTATION  OF  LUNGS 


459 


1736.  Pectoriloquy 

An  articulate  sound  heard 
normally  over  the  trachea. 
It  is  brought  out  best 
by  a  whisper. 

Bronchiectasis 

*Cavity  in  Lung 

smooth- walled  and  com- 
municating with  bronchus 

Cirrhosis  of  Lung 
Consolidation,  Pulmonary 
over  a  large  bronchus 

Hydatids  of  Lung 
after  rupture 

Pleural  Effusion,  Large  (x) 
upper  lobe 

Pneumonia,  Acute,  n.  (x) 

Pneumothorax,  Open 

It  sometimes  accompanies 
Skodaic  Resonance. 

1737.  Bacelli's  Sign 

Whispering  Pectoriloquy  is 
heard  through  a  serous, 
but  not  through  a  puru- 
lent, effusion  (?). 

1738.  D'Espine's  Sign 

Auscultating  over  the  spi- 
nous processes,  pectori- 
loquy ceases  normally  at 
the  bifurcation  of  the 
trachea.  In  infants  this 
is  opposite  the  7th  cer- 
vical vertebra  (in  adults 
the  3rd  dorsal).  If 
heard  lower,  the  bronchial 
glands  are  enlarged. 

1739.  Echophony 

A  short  sound  which  follows 
the  vocal  resonance  like 
an  echo. 

Woillez'  Disease 


1740.  Friction  Sound 

A  to-and-fro  sound  pro- 
duced by  the  friction  of 
roughened  serous  mem- 
brane. It  is  unaffected 
by  coughing,  and  can  be 
imitated  by  placing  one 
hand  flat  over  the  ear 
and  rubbing  on  it  slowly 
to  and  fro  with  a  finger 
of  the  other  hand. 

Abscess,  Hepatic 
Bronchial  Glands,  Enlarged 

between  scapulae 
Cancer  of  Liver 

,,        Pleura 
Diaphragmatic  Pleurisy 

lower  end  of  sternum 
Embolism  of  Lung 
Fracture  of  Rib 
Interlobular  Emphysema 
Mediastinitis,  Acute 
Perihepatitis 

audible  all  over  right  side 
Perisplenitis 
Peritonitis  (x) 

over  lower  chest 
Phthisis  (x) 

at  apex 
Pleura,  Thickened  Adherent 
creaking 
*Pleurisy,  i.  and  in. 
Pysemic  Abscess 
Recent  Adhesion 

spongy 
Subphrenic  Abscess 

xiphoid  cartilage 
Tubercles  on  Pleura  (x) 

blade,  and 
shoulder- joint  friction 
may  mislead,  but  these 
can  be  evoked  by  move- 
ments of  the  arm  even 
when  the  breath  is  held. 

1736-1740 


*#*  Shoulder 


460 


AUSCULTATION  OF  LUNGS 


1741.  Perez'  Sign 

A  friction  sound  heard  over 
the  sternum  when  the 
patient  raises  his  left 
hand  to  his  head  and  lets 
it  fall  again. 

Aneurysm  of  Aorta 
Mediastinal  Tumour 


1742.  Succussion  Sound 

The  patient  should  be  taken 
by  the  shoulders  and 
shaken  from  side  to  side. 
The  sound  is  due  to  the 
splashing  of  fluid  mixed 
with  air. 

Abscess  of  Lung 

„     Subphrenic 
Diaphragmatic  Hernia 
Gangrene  of  Lung 
Hydropneumopericardium 
*Hydropneumothorax 


Phthisis,  m. 
large  thin-walled  cavity 

Pyopneumopericardium 
Pyopneumothorax 

1743.  Tuning  Fork  Sound 

This  is  periodically  invented 
and  discarded  as  worth- 
less. Years  ago  the 
writer  was  one  of  the 
many  culprits. 

1744.  Symmetrical    Lung 
Diseases 

Acute  Miliary  Tuberculosis 
Bronchial  Catarrh 
Bronchitis 
Broncho -pneumonia 
Congestion,  Hypostatic 
Emphysema,  Vesicular 

except  the  compensatory 
form 


1741-1744 


AUSCULTATION  OF  HEART 


461 


AUSCULTATION    OF   THE    HEART 


Fig.  14. — Points  of  Maximum  Intensity  for  Murmurs 


Acute  Endocarditis,  A. 
Aortic  Regurgitation,  B,  C. 

.,       Stenosis,  C,  F. 

and  back 
Hsemic  Murmurs,  D. 
Mitral  Regurgitation,  A,  E. 

and  back 


Mitral  Stenosis,  A. 
Patent  Duct,  D. 
Pulmonary  Murmurs,  D,  O. 
Tricuspid  Regurgitation,  B. 

C. 
Tricuspid  Stenosis,  B. 


1745.  It  is  not  always  easy  to  distinguish  the  first  from  the 
second  sound.  To  do  so,  start  at  the  apex — the  systolic  sound 
will  synchronise  with  the  upheaval ;  then,  with  the  finger  on 
this  spot,  move  the  stethoscope  gradually  towards  the  base, 
keeping  in  touch  all  the  time  with  the  upheaval.  The  radial 
pulse  is  about  y1^  second  later  than  the  heart's  impulse  and  is 
therefore  not  suited  for  timing  murmurs.  The  rhythm  of  the 
mitral  and  tricuspid  sounds  is  usually  a  trochee  (-<_»)  ;  that  of 
the  aortic  and  pulmonary,  iambic  (u  — ).  The  cardiac  cycle,  with 
a  pulse  rate  of  72,  is  0*8  second  ;   divided  as  follows  : 


Auricular  Systole  O'l 

Ventricular  Systole  0*3 


Auricular  Diastole  0*7 

Ventricular  Diastole  0*5 


The  heart  sounds  are  heard  better  in  the  upright  than  in  the 
recumbent  posture,  particularly  in  fat  subjects. 

1745 


462 


AUSCULTATION  OF  HEART 


1746.  MURMURS 

A  murmur  is  not  necessarily  evidence  of  diseased  valves,  for 
the  cusps  may  fail  to  meet  owing  to  dilatation  of  the  ventricle 
or  of  the  valve  ring.  Further,  the  stenosis  revealed  by  a  given 
murmur  may  be  only  relative,  for  even  a  dilated  orifice  may  be 
small  in  proportion  to  a  greatly  dilated  ventricle. 

1747.  Potain's  Murmurs 

These  are  functional.  That  due  to  excited  cardiac  action  is 
systolic  and  is  heard  in  the  fourth  left  space  near  the  sternum  ;  while 
the  cardio-pulmonary  murmur,  which  is  meso-systolic,  is  heard  near 
the  apex  or  in  the  third  or  fourth  space.  It  may  be  most  evident  with 
in-  or  ex-piration ;  but  is  not  equally  audible  with  both.  Both 
murmurs  are  audible  in  the  upright  position  only. 

1748.  APEX  MURMURS 


1749.  Presystolic  Murmurs 

Aortic  Regurgitation  (x) 

Flint's  Murmur ;  heard  only 
when  the  ventricle  is 
dilated. 

Endocarditis 

Mitral  Regurgitation  (x) 

Mitral  Stenosis 

U  soft ;  brought  out  by 
exercise,  or,  if  heart 
turbulent,  by  digitalis. 
It  disappears  when  auricu- 
lar fibrillation  intervenes. 

Tricuspid  Regurgitation  (x) 

Tricuspid  Stenosis 

loudest  at  base  of  ensiform 
cartilage,  or  at  the  in- 
sertion of  the  5th  right 
rib  ;  not  heard  at  back 


1750.  Systolic  Murmurs 

Acute  Endocarditis       t 
blowing — variable 

Mitral  Regurgitation 

loud  and  blowing ;  ncard 
in  left  axilla  and  left 
vertebral  groove 

Tricuspid  Regurgitation 
base   of   ensiform   cartilage 


1746-1750 


AUSCULTATION  OF  HEART 


463 


BASE  MURMURS 


1751.  Systolic  Functional 

Low-pitched ;  heard  best 
at  2nd  left  space  in  60  per 
cent,  of  cases  ;  rarely  on 
the  right  side  or  at  apex. 

Addison's  Disease 

Anaemia  (385) 

Cachexia,  Cancerous 

Chlorosis 

Convalescence  from  Fevers 

Exophthalmic  Goitre 

Haemorrhage 

Wasting  Diseases 

1752.  Systolic  Organic 

Aneurysm,    Intrapericardial 

booming 
*Aortic  Stenosis 

loud ;  heard  at  mid-sternum, 
2nd  right  space,  and  left 
vertebral  groove 

Aortitis 

harsh 

Dissecting  Aneurysm 

heard  at  left  vertebral 
groove 

Malformation  of  Heart 

sharp 
Mediastinal  Tumour 

pressing  on  aorta 


Perforation  of  Septum  Ven- 

triculorum 

heard  best  at  mid-sternum 
between  the  third  spaces 

Pulmonary  Stenosis 
2nd  and  3rd  left  spaces 

Roughness  and  Rigidity  of 
Aortic  Valves 

Roughness  of  Conus  arteri- 
osus 

1753.  Diastolic  Organic 

Acute  Endocarditis  (x) 

on  infective  endocarditis 
setting  in,  the  old  murmur 
changes  its  character 

Aneurysm  of  Aorta 
*Aortic  Regurgitation 

blowing ;  heard  best'  at 
2nd  right  space  and  at 
junction  of  3rd  left  carti- 
lage with  sternum.  Con- 
ducted to  ensiform  carti- 
lage, but  not  to  back 

Dilatation   of   Aorta   above 

Valve 

Patent  Ductus  Arteriosus 

third  left  space — partly  sys- 
tolic 

Pulmonary   Regurgitation 

Rupture  of  Aortic  Cusp 

***  It  must  not  be  forgotten 
that  stenosis  and  in- 
sufficience   may   co-exist. 


1751-1753 


464 


AUSCULTATION  OF  HEART 


ALTERED  FIRST  SOUND 


175*.  Weak  or  Muffled 

In  general,  this  is  a  sign 
of  extreme  weakness. 
When  occurring  in  the 
course  of  a  fever,  it  is 
known  as  '  Stokes'  Sign.' 

Ague  (cold  stage) 

Cholera 

Collapse 

Emphysema 

Endocarditis,  Acute 

Fatty  Heart 

Gouty  Heart 

Obesity 

Pericardial  Effusion 

Pernicious  Intermittent 

Prostration 

Trance 

Typhic  State  (62) 

Typhus 

1755.  Loud  at  Apex 

A  transient  accentuation 
may  be  due  to  nervous- 
ness. Prolongation  means 
increased  blood  pressure. 

Exophthalmic  Goitre 

Meteorism 

Mitral  Stenosis 

'  slapping ' 
Neurasthenia 


Pneumothorax 
ringing 

Valvular  Disease 

with    disturbed    compensa- 
tion 


1756.  Differential 

Aortic  Aneurysm 
often  absent 

Aortic  Regurgitation 
murmurish   at   base 

Arterio-sclerosis 
prolonged 

Dilatation 

short  and  loud 

Functional  Heart  Disease 
ringing 

Hypertrophy  of  Left  Ven- 
tricle 
booming 

Hypertrophy  of  Right  Ven- 
tricle 
distinct 

Mitral  Stenosis 

loud,   short,   and   sharp 

Myocarditis,  Acute 

sharp    at    first,    afterwards 
dull 


1754-1756 


AUSCULTATION  OF  HEART 


465 


1757.  HEART'S  PAUSES 

(See  Cardiac  Cycle,  1745) 


1758.  Equalised,     as     in     the 

foetal     heart     (embryo- 

cardia) 

Also  termed  '  tic-tac '  or 
'  pendulum  '  rhythm — a 
danger  signal. 

Fevers 

Heart  Failure,  Impending 


Nephritis 

Weakened  Heart  Muscle 


1759.  Second  Pause  Prolonged 

Digit  alinism 

Pneumonia 

Weak   and   Irritable   Heart 


1760.   ALTERED  SECOND  SOUND 

r  Accentuation  of  the  second  sound  is  systemic,  if  loudest  in  the 
2nd  or  3rd  right  space  ;  pulmonary  if  in  second  or  third  left.  The 
pulmonary  second  sound  is  louder  than  the  aortic  up  to  puberty  ; 
but  after  this,  the  aortic  gradually  gets  the  louder.  In  patients  over 
fifty,  the  second  sound  becomes  louder  than  the  first. 


Anaemia 
sharp 

Aneurysm 

drum-like 

Aortic  Regurgitation 

valvular  form,  feeble ; 
aortitic  form,  accentu- 
ated 

Aortic  Stenosis 

indistinct 
Aortitis 

accented 
Arterio-sclerosis 

audible  at  angle  of  right 
scapula 

Dilatation,  Acute 
accented 

Fatty  Degeneration 
sharp 


2  H 


Fibroid  Heart 

accented 

Hypertrophy  (1829) 

left,     loud ;       right,     very 
loud 

Mitral  Regurgitation 
accentuated  pulmonary 

Mitral  Stenosis 

accentuated  pulmonary 

Myocarditis,  Acute 

sharp    at    first,    afterwards 
dull 

Pericarditis,  I. 

ringing     sound — over     pul- 
monary area 

Pericardium,  Adherent 

inaudible  at  apex 

Rough    and    Rigid    Aortic 
Valves 
loud 

1757-1760 


466 


AUSCULTATION  OF  HEART 


1761.  Reduplication 

Reduplication  is  due  to 
want  of  I  synchronism  in 
the  closure  of  the  aortic 
and  pulmonary  valves. 
Reduplication  of  the  first 
sound  gives  an  anapest 
u  o  — ;  of  the  second 
sound,  a  dactyl  — o  u. 

Anaemia 
Aneurysm 
Arterio-sclerosis 
of  first  sound 

Dyspepsia 
Emphysema 
Hypertrophy,  Left 
of  first  sound  at  apex 

Hypertrophy,  Right 

of  second  sound 
Mitral  Regurgitation 
Mitral  Stenosis 

of  second  sound  at  base 
(Sansom's  Sign) 

Nephritis,  Chronic 

Postural  Albuminuria 

of  second  sound  in  recum- 
bent position 

Pyrexia  (295) 

It  is  present  occasionally 
in  healthy  persons. 


1762.  Bruit  de  Rappel 

(Sound  of  Recall u) 

*Mitral  Stenosis 


1763.  Lapping 

A  sound  resembling  that 
of  a  cat  lapping  milk  has 
been  heard  with  a  slit- 
like rupture  of  the  aorta. 


1764.  Galloping     or     Triple 
Rhythm 

(Bruit  de  galop) 
Anaemia 
Dilated  Heart 
Fevers,  in. 

Heart,  Hypertrophy  of 
Myocarditis 
Nephritis,  Chronic 
*Pericarditis,  Acute 


1765.  Nodal  Rhythm 

The  auricles  and  ventricles 
contract  simultaneously  : 
common  in — 

Mitral  Stenosis 
Rheumatic  Heart 


1766.  Irregular  Action 

This  in  its  extreme  form  is 
termed  Delirium  Cordis. 
It  is  a  sign  of  failing 
compensation. 

Aneurysm    (esp.    intraperi- 

cardial) 

tumultuous 

Aneurysm  of  Heart 
Ascites 

Auricular  Fibrillation  (259) 
Chorea 

Digitalis  in  Excess 
cumulative  action 
Displaced  Heart  (1600) 
Distension  of  Stomach 
Gout,  Undeveloped 
Influenza 

Mitral  Regurgitation 
Neurasthenia 
Neuritis,  Multiple 
Rupture  of  Aortic  Cusp 
1761-1766 


AUSCULTATION  OF  HEART 


467 


Irregular  Action — continued 
Spermatorrhoea 

Also  from  abuse  of  tea  or 
tobacco 

(See  Palpitation,  219,  and 
Arrhythmia,  258) 

1767.  Cliquetis  Metallique 

A  rattling  systolic  tone 
heard  over  the  ventricles 
— rare 

Hypertrophy  of  Heart 
Palpitation  (219) 

1768.  Splashing  Sound 

Audible  at  a  distance. 

Hydropneumopericardium 
Pyopneurnopericardiuni 

It  sometimes  resembles  the 
sound  of  a  water  mill — 
'  Bruit  de  Moulin.' 

1769.  Friction  Sound 

Unlike  a  pleural  friction 
sound,  this  is  audible 
when  the  patient  holds 
his  breath ;  further,  it  is 
increased  or  brought  out 
by  the  pressure  of  the 
stethoscope.  The  inten- 
sity point  may  change 
with  the  position  of  the 
body  ;  it  is  usually  loudest 
at  the  base. 


Mediastinitis 
♦Pericarditis 
Perihepatitis 
low-pitched 

Pleurisy      of      Overlapping 

Lung 

rarely    audible    when    not 
breathing 

Tubercles  of  Peritonaeum  (x) 
It  is  also  present  in  Sturges' 
Carditis,  which  is  a  com- 
bination   of     endo-    and 
peri-carditis. 


1770.  Auricular  Flutter 

The  auricular  contractions 
number  200  or  more  per 
minute — the  radial  pulse 
being  usually  one  half 
or  one  third  of  this.  It 
indicates  degeneration  of 
the  auricle. 

Cardio-sclerosis 
Diphtheritic  Neuritis 
Influenza 
Valvular  Disease 


1771.  Crepitation  Synchronous 
with   Heart's  Action 

Interstitial    Emphysema    of 
Mediastinum 


2  h  2 


1766-1771 


468 


ARTERIAL  MURMURS 


1772.  VENOUS   MURMURS 


Care  must  bo  taken  to  prevent 
upon  the  lumen  of  a  vein,  since  a 
duced  in  this  way. 

1773.  Praesytolic 

Health 
in  recumbent  position 

1774.  Systolic 

Tricuspid  Regurgitation 

1775.  Diastolic 

Anaemia 

Dilatation  of  Aorta 

Hypertrophy 

Strong  Aortic  Pulsation 

1776.  Venous  Hum 

'  Bruit  de  diable '  *  or 
Nun's  Murmur 

To  hear  this,  the  stetho- 
scope should  be  placed 
very  lightly  over  the 
clavicular  insertion  of 
the  sterno -mastoid. 


the  stethoscope  from  impinging 
murmur  can  bo  artificially  pro- 

Ancemia 
Chlorosis 

in  upright  position 
Cirrhosis  of  Liver  (x) 

over    epigastrium — louder 
on  expiration 

Nsevus 

Spleen,  Enlarged 
Uterine  Souffle 
Varix 

*  '  Diable '    means    hero    a 
humming-top. 


1777.  Eustace  Smith's  Sign 

A  venous  hum  at  manu- 
brium with  patient's  head 
thrown  back. 

Bronchial  Glands,  Enlarged 


1778.   ARTERIAL  MURMURS 

In  general,  a  systolic  murmur  heard  over  a  portion  of  an  artery 

means   local   arterio-sclerosis.     Whatever   causes   pulsus   celer   will 

cause  an  arterial  murmur  (250). 

1779.  Carotid   and   Subclavian 

Systolic  Murmur 

Anaemia 

Aortic  Regurgitation 


diastolic 
Aortic  Stenosis 

systolic 
Arterio-sclerosis 

also  heard  elsewhere 
Cervical  Rib 


*#*  '  When  the  second  sound 
is  audible  in  the  carotids, 
the  aortic  valves  are 
still  fairly  efficient.' 

(W.  Broadbent.) 

1780.  Femoral  Double  Murmur 

The  Double  Murmur  of 
Duroziez  is  brought  out 
by  graduated  pressure  of 
the  stethoscope  upon  the 
femoral  artery  after  the 
degree  necessary  to  pro- 
duce  the  normal  sys- 
tolic pressure  murmur  is 
exceeded. 

1772-1780 


ARTERIAL  MURMURS— AUSCULTATION         469 


Femoral  Double  Murmur — 
continued 
Aneurysm 

Aortic  Regurgitation 
Chlorosis 

Exophthalmic  Goitre 
Lead-poisoning 
Mitral  Stenosis 

1781.  Palmar  Arch  Murmur 
Aortic  Regurgitation 

1782.  Glasgow's  Sign 

A  systolic  sound  heard  over 
the  brachial  artery. 

Aneurysm  of  Aorta 

1783.  Fcetal  Heart 

This  is  rarely  heard  before 
the  fifth  month.  The 
rate  is  from  135  to  140, 
and  the   situation   where 


it  is  normally  tho  loudest 
is  midway  between  the 
ant.  sup.  spine  and  the 
umbilicus.  When  the 
point  of  maximum  in- 
tensity is  well  above  the 
level  of  the  navel,  the 
case  is  one  of  breech 
presentation.  When  the 
sounds  are  loud  and  the 
uterus  is  small,  ectopic 
gestation  is  indicated. 


1784.  Aneurysmal  Bruit 
Aneurysm  in  general 

unless  filled  with  clot 
Aneurysm  of  Aorta 

with  systolic  murmur 
Aneurysm     of     Abdominal 

Aorta 

with  post-systolic   murmur 

Pulsating  Sarcoma 


AUSCULTATION  OF  OTHER  PARTS 


1785.  Auscultation  of  Head 

The  systolic  murmur  some- 
times heard  over  the  ver- 
tex in  children  aged  from 
three  months  to  six  years, 
and  formerly  attributed 
to  Rickets,  is  of  no 
diagnostic  importance. 


1736.  Buccal  Auscultation 

The  patient  after  coughing 
and  expectorating  freely 
places  over  his  open 
mouth  a  cloth,  to  which 
the  physician  applies  his 
ear.  A  sound  resembling 
a  sub -crepitant  rale  indi- 
cates : — 


Phthisis 

consolidation  and  softening 
at  the  apex 

1787.  Auscultation  of  (Eso- 
phagus 
The  stethoscope  should  be 
placed  on  the  left  side 
of  the  trachea  or  of  the 
six  upper  dorsal  spines. 
The  sound  of  swallowing 
fluid  is  delayed  in  : — 

(Esophageal  Stenosis 
cancerous  or  fibrous 

Tumours 

impinging  on  lumen 

(See  693) 

1780-1787 


470 


ABDOMINAL  AUSCULTATION 


1788.  ABDOMINAL   AUSCULTATION 


1789.  Swallowing  Sound 

A  short  splashing  murmur 
heard  in  health  imme- 
diately after  swallowing 
fluid. 

Absent  in 

(Esophageal  Stenosis 

1790.  Friction  Sound 

Rare ;  loudest  over  liver 
and  spleen. 

Leukaemia,  Splenic 

Perihepatitis 

Peritonitis 

1791.  Silenced  Borborygmi 

Borborygmi  should  be 
always  audible  with  the 
stethoscope  ;  if  they  are 
not,  it  is  a  sign  that 
peristalsis  is  arrested,  as  in 

Acute  Peritonitis 


Other    Stomach    Tests 

1792.  Wolfler's  (a)  Sign 

When  less  can  be  with- 
drawn from  the  stomach 
than  has  been  introduced 
into  it  by  tube,  the 
indication  is — ■ 

Hour-glass  Contraction 

1793.  Wolfler's  (b)  Sign 

A  foul  flow  after  apparently 
complete  cleansing  by 
lavage. 

Hour-glass  Contraction 


1794.  Jaworski's  Test 

A  succussion  splash  in  the 
pyloric  half  after  siphon- 
ago  of  the  cardiac  sac. 

Hour-glass  Contraction 

1795.  Gaseous  Test 

On  taking  the  two  parts 
of  a  Seidlitz  powder 
separately,  a  peculiar 
gurgling  sound  is  heard 
below  the  xiphoid  carti- 
lage (not  at  the  pylorus). 

Hour-glass  Contraction 

*„.*  Moynihan's  Test  consists 
in  the  observation  of 
two  distinct  sacs  after 
inflation. 

1796.  Stomach  Splash 

The  examination  should  be 
made  at  least  four  hours 
after  a  meal. 

Atony  of  Stomach 
Dilatation  of  Stomach 
Distended  Colon  (x) 
Gastroptosis 
Hour-glass  Contraction 
Hydro-pneumoperitonaeum 
Perforation  (x) 
Pneumoperitoneum  (x) 

1797.  Succussion  Sound,  Ab- 
dominal 

Abscess,  Subphrenic 

after    opening    into    the 
stomach 

Aerophagia  Nervosa 
Dilatation  of  Caecum,  Colon 

or  Stomach 
Hydro-pneumoperitonaeum 

1788-1797 


ABDOMINAL  AUSCULTATION,  ETC. 


47i 


Succussion      Sound,     Abdo- 
minal— continued 
Idiopathic      Dilatation      of 

Colon 
Pneumaturia 

It  may  be  heard  in  health, 
when  a  large  quantity 
of  fluid  has  been  just 
swallowed. 


1793.  Bell  Sound 
Distended  Colon  (x) 
Enteric  Fever  (x) 

When  heard  all  over  the 
abdomen  it  is  said  to 
indicate  perforation  of 
the  bowel. 


1799.  Sahli's  Whistle  (x) 

Due     to       flatus      passing 
through  a  chink. 

Stenosed  Intestine 


1800.  Brenner's  Sign 

A  metallic  rub  over  the 
12th  left  rib  behind  when 
the  patient  sits  up. 

Perforation  of  Stomach 

It  is  due  to  air  bubbles 
collecting  between  the 
diaphragm  and  the 
stomach. 


AUSCULTATION   OVER    BONES,    ETC. 


1801.  Auscultation  of  Bones 

Crepitation  over  seat 
of  fracture.  Especially 
valuable  in  fractures  of 
the  spinal  column  and 
those  in  remote  situations. 


1802.  Auscultation  of  Joints 

Bared  Bone 

scraping  sound 
Erosion  of  Cartilages 

'  fine  scrunch ' 
Synovial  Membrane,  Swollen 

fine  crackle 

A  gross  snap  or  crackling 
often  audible  at  a  distance 
occurs  in  old  rheumatism 
and  rheumatoid  arthritis  ; 
but  is  of  little  import- 
ance. Something  like  it 
is  often  heard  in  health — 
the  '  vacuum  sound  '  of 
Garrod.  _  (See  916) 


* 


1797-1802 


PART  VI 


MISCELLANEOUS 


Contractions  :  u,  usually  ;  x,  exceptionally  ;   *,  the  most  probable 
diseases  ;  I,  First  stage  ;  11,  Second  stage  ;  ni,  Final  stage. 


1803.  TIME  AND  SEASON 


1804.  Worse  at  Night 

Acute  Laryngitis 
Asthma,  Spasmodic 
small  hours 

Bones,  Diseases  of 

Diphtheritic  Laryngitis 

Influenza 

Joints,  Diseases  of 


Renal  Calculus 
Rheumatism,  Chronic 
Spasmodic  Laryngitis 
Syphilitic  Pains 

The  temperature  in  fevers, 
etc.,  is  usually  higher  at 
night  (295).  For  Pain 
see  152. 


1805.  TIME  OF  YEAR  (London  Mortality) 

Some  diseases  will  be  found  under  two  headings. 


1806.  Winter,  Prevalent  in 

Asthma 

Bronchitis 

Cerebro -spinal  Meningitis 

Diphtheria 

Enteric  Fever 

Erysipelas 

Gout 

Heart  Disease 

Hooping  Cough 

Laryngitis 


Measles 

Phthisis 

Pleurisy 

Pneumonia 

Puerperal  Septicaemia 

Quinsy 

Raynaud's  Disease 

Rheumatism 

Spasmus  nutans 

Variola 

1803-1806 


SEASON 


473 


1807.  Spring,  Prevalent  in 

Asthma 

Bronchitis 

Gout 

Hydrarthrosis,  Intermittent 

Laryngitis 

Measles 

Phthisis 

Pleurisy 

Pneumonia 

Purpura 

Scurvy 

Variola 

Vincent's  Angina 

1808.  Summer,  Prevalent  in 

Cholera 

Cholerine 

Diarrhoea 

Dysentery 

Enteritis 


Infantile  Paralysis 
Malta  Fever 
Tabes  mesenterica 
Weil's  Disease 

1809.  Autumn,  Prevalent  in 

Cholera 
Cholerine 
Diphtheria 
Dysentery 
Enteric  Fever 
Erysipelas 
Heart  Disease 
Hooping  Cough 
Infantile  Paralysis 
Puerperal  Fever 
Quinsy 
Rheumatism 
Scarlatina 
Weil's  Disease 


1807-1809 


474 


EXOTIC  DISEASES,  ETC 


1810.  EXOTIC  DISEASES,  ETC. 

(As  regards  England) 

Ainhum 

Hindostan  and  Guinea 

Aketama 

West  Africa 

Ankylostomiasis 

India,  Egypt,  West  Indies, 


more  than  in  England. 
Beri-beri 

rice-eating  countries 
Bilharzia  hsematobia 

Egypt,  Cape,  etc. 
Bothriocephalus 

Switzerland,    Italy,    Baltic, 
etc. 

Bruhl's  Disease 
Bualama  Boil 
Chigoe 

Chorea  Major 
chiefly  S.  Europe. 

Cretinism 
Dengue 

West  Indies,  etc. 
Distomiasis 

China,  Japan,  etc. 

Dubini's  Chorea 
Dysentery 
Elephantiasis 
Gerlier's  Disease 
Switzerland 


Hepatic  Abscess 
Hepatitis,  Acute 
Kala  Azar 
India 

Lathyrism 
Leprosy 
Mycetoma 
Nakra 

Paroxysmal   Haemoglobin- 
uria 
Tropics  and  S.  Europe 
Pellagra 

Italy,  R-oumania,  U.S.,  and, 
rarely,  England. 

Pernicious  Intermittent 
Pinta 
Plague 
Ponos 
Greece 

Remittent  Fever 
Sprue 

esp.  Malaya 

Trachoma 

Poland,  Belgium 

Trypanosomiasis 
Yaws 

black  races  chiefly 
Yellow  Fever 

W.  Indies,  W.  Africa 


1810 


RADIOGRAPHY 


475 


RADIOGRAPHY 

1811.  Rontgen  Rays 

The  higher  the  atomic  weight  of  an  element,  the  more 
impenetrable  is  it  to  X-rays.  The  hollow  viscera  should  be 
examined  after  a  meal  containing  4  to  6  oz.  of  bismuth  car- 
bonate, or  10  to  12  oz.  of  sulphate  of  barium.  The  latter, 
mixed  with  kaolin  and  warm  water,  may  be  administered  as 
an  enema.  An  ordinary  breakfast  may  be  taken  two  hours 
before  the  test  is  made.  Beck's  Paste  is  used  for  investigating 
fistulous  openings  ;  it  consists  of  one  part  of  bismuth  sub- 
nitrate  to  two  of  warmed  vaseline.  Collargol  (7  per  cent.) 
injection  is  used  in  examination  of  the  ureter  and  kidney. 
The  calculi  that  give  the  best  results  are  cystin  and  the 
oxalates,  then  the  phosphatic,  and  lastly  the  uric  acid. 


Useful  in  diagnosing — 
Acromegaly 

Sella  Turcica  enlarged 

Aneurysms 

Bronchial  Glands,  Enlarged 

Cancer  of  Bone      , 

spotty,  with  irregular  out- 
lines 

Cavities,  Lung 

Cervical  Rib 

Charcot's  Joint 

diminished      opacity      near 
joint 

Coxa  valga 

„      vara 
Diaphragmatic  Abscess 
,,  Hernia 

Dilatation  of  Stomach 
Dislocations 
Displacements  of  Heart 
„         of  Liver 
Disused  Limb 

thinning  of  bone 


Effusion,  Pericardial 

,,       Pleural 
Enteroliths 
Exostoses 
Fractures 
Gallstones 

periphery  dark 

Gangrene  of  Lung 
Gastric  Cancer 

lessened  peristalsis 
Gastric  Ulcer 

bismuth  clings  to  it 
Gastroptosis 
Gouty  Deposits 
Growths,  Internal 
Heart  Enlargements 
Hour-glass  Stomach 
Ileal  Kink 
Impacted  Foreign  Bodies 

especially  metal  objects 

Intestinal  Obstruction 
Liver,  Enlarged 

1811 


476 


RADI0C4RAPHY 


Rontgen  Rays — continued 
Mediastinal  Abscess 
Myelo-sarcoma 

bone  transparent 
Myositis  Ossificans 
(Esophageal  Pouch 

„  Stricture 

Osteo-arthritis 
osteophytes,  thinning  of  shaft 

Pancreatic  Calculi 
Pericardial  Effusion 
pulsating  shadow 

Persistent  Ductus  Botalli 

Phleboliths 

Phthisis,  I. 

diminished      diaphragmatic 
movements 

Pituitarism 
Pneumonia 
Pneumothorax 
Psammoma  Cerebri 
Pyloric  Stenosis 
Renal  Calculus 
Rheumatoid  Arthritis 
bone, 


thinning     of 
outlines 


clear 


Sphenoidal  Sinus  Disease 
Tendon,  Ruptured 
Thymus,  Enlarged 


Tuberculous  Bone 

outlines    fluffy    and    ill- de- 
fined 

Tumours,  Solid 
Ureteral  Calculus 
Vesical  Calculus 
V-shaped  Colon 


1812.  William's    Phenomenon 

Restricted  movement  of 
the  diaphragm  on  the 
affected  side. 


Aneurysm    of 
Phthisis 


Desc.    Aorta 


1813.  Frimadeau's  Sign 

The  dilatation  above  a 
stricture  of  the  oeso- 
phagus is  cup- shaped,  if 
malignant ;  conical,  if 
fibrous. 


1814.  Radium  Rays 

These  rays  are  said  to  be 
visible  in  cases  of  blind- 
ness due  solely  to — 


Corneal  Opacity 
Glaucoma 


1811-1814 


TUBERCULIN  TESTS 


477 


1815.  TUBERCULIN  TESTS 


1816.  Conjunctival  f  Reaction 
(Calmette  and  Wolff- 
Eisner) 

A  freshly  prepared  1  per 
cent,  solution  of  Koch's 
Old  Tuberculin  (dried) 
in  normal  saline  solution 
should  be  made,  and  a 
little  dropped  on  to  the 
conjunctiva.  The  reac- 
tion ranges  between 
slight  reddening  of  the 
caruncle  and  intense  con- 
junctivitis with  chemosis. 
It  usually  begins  within 
10  hours,  reaches  its 
height  on  the  second 
day,  and  fades  on  the 
fifth  day  ;  the  intensity 
of  the  reaction  is  not  in 
proportion  to  the  extent 
of  the  disease.  88  per 
cent,  of  cases  of  certain 
tuberculosis  give  the  re- 
action, and  12  per  cent. 
of  non-tuberculous  cases. 
It  has  been  known  to 
cause  blindness  and  is 
less  used  now. 

Gonorrhoea 
Rheumatism  (x) 
Skin  Diseases,  Many 
*Tuberculosis,  Local  or 
General 


1817.  Pagano's  Reaction 

Calmette's  Reagent  is 
applied  to  the  meatus 
urinarius  instead  of  the 
conjunctiva. 


1818.  Moro's  Reaction 

An  eruption  of  pink  or  red 
papules  after  an  applica- 
tion to  the  skin  of  an 
ointment  composed  of 
5  c.c.  old  tuberculin  in  5 
grammes  of  wool  fat. 

Tuberculosis 


1819.  Von  Pirquet's  Cutaneous 
Reaction 

The     solution     consists     of 
Koch's    Old    Tuberculin, 

1  part ;  of  5  per  cent, 
carbolic  glycerin,  1  part ; 
and  of  sodium  chloride 
solution  (0*85  per  cent.), 

2  parts.  The  skin  on  the 
inner  side  of  the  forearm, 
previously  washed  with 
ether,  is  lightly  scarified 
at  two  points.  On  one 
the  above  preparation  is 
placed  ;  on  the  other,  the 
preparation  minus  the 
tuberculin.  On  the  first, 
a  hyperaemic  papule  sur- 
rounded by  a  bright  red 
zone  the  size  of  a  florin 
will  form  within  24  hours, 
the  papule  becoming  later 
a  vesicle,  and  finally  a 
crust.     The     second     or 

1815-1819 


478 


TUBERCULIN  TESTS,  ETC. 


*  * 


Von    Pirquet's    Reaction — 
continued 

'  control '  scarification 
shows  only  slight  con- 
gestion and  swelling.  No 
constitutional  symptoms 
should  ensue.  Present 
in  : — 

Tuberculosis 
88  per  cent. 

Cases     not      demonstrably 

tuberculous  10  per  cent. 

Neither  Acute  Miliary 
Tuberculosis  nor  late 
severe  Phthisis  will  give 
a  reaction. 


1820.  Escherich's  Test 

This  differs  from  V.  Pirquet's 
test  in  that  the  tuber- 
culin is  injected  sub- 
cutaneously.  It  is  of 
doubtful  value. 


1821.  Guinea  Pig  Test 

The  inoculated  animals  die 
within  three  weeks  of 
tuberculosis. 


1822.  Tuberculin  Test 

Not  without  danger,  espe- 
cially if  the  patient  is 
already  feverish.  Not 
often  used  now. 

If,  5  to  20  hours  after  an 
injection,  there  is  a  rise 
in  temperature  of  2°  to 
3°  F.  and  the  physical 
signs  are  plainer,  the 
indication  is 

Tuberculosis 


1323.  Deehan's    Typhoid  Re- 
action 

This  is  an  adaptation  to 
Typhoid  of  von  Pirquet's 
tuberculin  reaction  and 
gave  early  positive  results 
in  twelve  consecutive 
cases.  The  strength  of 
the  re-agent  is  four  billions 
of  b.  typhosus  to  1  c.c. 
of  saline  solution. 


1824.  Noguchi's    Luetin   Test 

An  extract  of  a  pure  culture 
of  Spirochaeta  Pallida  is 
injected  intradermically 
in  the  arm. 

The  negative  reaction  is 
erythema  and  a  papule 
which  subsides  within 
five  days. 

The  positive  result  is  a  large 
papule  which  may  become 
pustulous  and  lasts  ten 
days  or  more. 

Parasyphilis 
Syphilis,  Congenital 

„       Latent 

,,       Tertiary 

The  results  are  but  little 
affected  by  mercurial 
treatment. 


1825.  Waterhouse  Pus  Test 

When  pain  in  a  local  in- 
flammation is  increased 
by  the  application  of  a 
Bier's  Bandage,  pus  is 
present. 


1819-1825 


TUBERCULIN  TESTS,  ETC. 


479 


1826.  Drug  Diagnosis 

Rapid    amelioration    under 
treatment. 

Antipyrin — Neuralgia 

Emetin  Hydrobrom. 

Amoebic  Dysentery 

Iodides — Syphilis 

Qui  nine — Malaria 

Salicylates — Rheumatism 

(except    the    gonorrheal 
form) 

Salvarsan — Syphilis 
Thyroidin — Myxoedema 
Trinitrin — Angina  Pectoris 
Allied  to  this  aid  to  diagnosis 
is    that    of  Addison's 
Disease    by   the    marked 
intolerance  of  arsenic  that 
is  characteristic  of  it. 


1827.  Negative  Symptoms 

The  absence  of  a  symptom  is 
sometimes  as  important 
as  its  presence.  Where 
this  is  the  case,  a  note 
will  be  found  under  the 
appropriate    heading. 

1828.  Rarity 

Extreme  rarity  of  occur- 
rence of  a  disease  is  a 
presumption  against  the 
diagnosis  or  at  least  a 
warning  to  investigate 
very  fully. 


1826-1828 


480  SYMPTOMS— COMPLEX 

1829.  SYMPTOMS— COMPLEX 

With  some   of  the  conditions  they  include. 

The  number  is  that  of  the  section  containing  the  list  of 
diseases  in  which  the  symptom-complex  is  found. 

Anaemia. — Pallor  of  skin  and  mucous  membranes,  pale, 
pearly  conjunctiva,  waxy  ears,  breathlessness  on  exertion, 
palpitation,  headache,  amenorrhoea,  and,  sometimes,  oedema 
pedum.  The  term  '  Secondary  '  Anaemia  is  applied  to  the  form 
that  results  from  albuminuria,  cancer,  haemorrhage,  lactation, 
suppuration,  syphilis,  poisons,  and  high  temperature.  A  flushed 
face  is  not  inconsistent  with  anaemia ;  the  pale  palpebral 
conjunctiva  is  a  better  guide  than  the  skin  (385). 

Ascites. — Abdomen  distended  with  clear  free  fluid  (1704). 

Collapse. — Pallor,  cold  sweats,  pinched  features  (Facies 
Hippocratica),  feeble  action  of  heart,  nearly  imperceptible  and 
rapid  pulse,  partial  loss  of  consciousness  (235). 

Coma. — Loss  of  consciousness,  insensible  conjunctiva, 
stertorous  breathing,  napping  cheeks,  altered  pupils,  involuntary 
evacuations,  and  usually  a  slow  pulse  (64). 

Debility. — Weakness  of  limbs,  shortness  of  breath  on  exertion, 
weak  first  sound  of  heart  (233). 

Dyspepsia. — Pain  in  epigastrium,  sternum,  and  back,  following 
food;   together  with  flatulence  and  furred  tongue  (147). 

Acute  Dyspnoea. — Breath  short,  face  wet  and  livid, 
countenance  anxious,  alae  nasi  dilating,  speech  interrupted 
(1223). 

Hectic  State. — High  evening  temperature,  morning  remis- 
sions with  perspiration,  red  spot  on  cheek  of  otherwise  pale  face, 
eyes  bright,  mind  clear,  pulse  rapid  (299). 

Hyperpyrexia. — Temperature  over  106°,  delirium,  rapid 
dicrotous  pulse  (297). 

1829 


SYMPTOMS— COMPLEX 


481 


Hypertrophy  or  Heart 

Heart  displaced  downwards 
and  outwards,  heaving  im- 
pulse, accentuated  second 
sound. 

(a)  Left  Ventricle 

Aneurysm 

Aortic  Regurgitation 

or  '  cor  bovinum  ' 
Aortic  Stenosis 

slight  enlargement 
Arterio-sclerosis 
Athletics 
Chlorosis 
Cirrhosis  of  Kidney 


Cyanotic  Kidney 
Exophthalmic  Goitre 
Heart,  Fibroid 

,,       Syphilitic 
Mediastinal  Tumours 
Palpitation,  Long-continued 
Pericardium,  Adherent 
Pregnancy 
Tracheal  Stenosis 

(6)  Right  Ventricle 

Asthma 
Emphysema 
Mediastinal  Tumour 
Phthisis,  Chronic 


Irritant-poisoning. — Vomiting,  diarrhoea,  pain  and  tenderness 
in  epigastrium,  collapse. 

Jaundice. — Yellow  skin  and  conjunctiva,  dark  urine,  pale 
stools,  slow  pulse  (392). 

Meteorism  and  Tympanites. — Distended  abdomen,  displace- 
ment of  heart,  with  rapid  and  perhaps  irregular  action,  shortness 
of  breath  (1700). 

Portal  Obstruction. — Ascites  with,  later,  oedema  pedum ; 
jaundice  or  earthy  complexion,  enlarged  abdominal  veins, 
hemorrhoids  (1704). 

Pyrexia. — Thirst,  high  temperature,  rapid  pulse,  furred 
tongue,  scanty  high-coloured  urine  with  sediment  (295). 

Typhic  (or  Typhoid)  State. — Muttering  delirium,  stupor  or 
coma  vigil,  involuntary  evacuations,  subsultus  tendinum. 
temperature  104°  or  more,  passive  congestion  of  lungs  and  skin 
of  back,  finally  Cheyne-Stokes'  respiration  (62). 


2  i 


1829 


482 


SYNONYMS 


[1830.  SYNONYMS 

In  a  few  cases  thej  diseases  here  regarded  as  identical  are 
looked  upon  by  some  writers  as  distinct  entities.  Both  columns 
should  be  scrutinised. 


Achondroplasia 

Achorion  Quinckeanum 
Adeno  -lipomatosi  s 
Addison's  Disease 
Albert's  Disease 
Alibert's  Disease 
Amdas 

Anorexia  Nervosa 
Anterior  Poliomyelitis 

Anthrax 

Appendicitis  Larvata 

Area 

Arthritis  Deformans 

Ataxic  Paraplegia 

Ateleiosis  j ! 

Atrophic  Spinal  Paralysis, 

Acute 
Balfour's  Disease 
Ballet's  Disease 
Ballingall's  Disease 
Bamberger's  Disease 

Banti's  Disease 

Barlow's  Disease 

Bateman's  Disease 
Bazin's  Disease 
Beard's  Disease 
Begbie's  Disease 


Foetal    Rickets 
Fcetal    Cretinism 
Mouse  Favus 
Lipomatosis  Neurotica 
Asthenia  Pigmentosa 
Achillodynia 
Mycosis  Fungoides 
Varioloid 
Nervous  Atrophy 
Infantile  Paralysis 
j  Malignant  Pustule,  Charbon, 
(      Splenic  Fever 
Appendicitis  Dyspepsia 
Alopecia  Areata 
Rheumatoid  Arthritis 
Combined   Lateral  and  Pos- 
terior Sclerosis 
Primary  Infantilism 
Adult  form  of  Infantile  Para- 
lysis 
Chloroma 

Ophthalmoplegia  Externa 
Mycetoma 
Saltatory  Spasm 
(  Primary   Splenomegaly   with 
\      Cirrhotic  Liver 
[  Infantile  Scurvy 
(  Scurvy  Rickets 
Molluscum  Contagiosum 
Erythema  Induratum 
Neurasthenia 

Rhythmic  Localised  Chorea 
1830 


SYNONYMS 


483 


Beigel's  Disease 

= 

Bell's  Mania] 

=  ( 

Paralysis 

Bergeron's  Disease 

= 

Bernhardt's  Paresthesia 

= 

Biernier's  Anaemia 

= 

Blackwater  Fever 

-J 

Botulism 

Bouillaud's  Disease 

= 

Bright' s  Disease,  Acute 

= 

Brill's  Disease 

= 

Bruhl's  Disease 

= 

Buhl's  Disease 

= 

Bulbar  Paralysis 

Caisson  Disease 
Carrion's  Disease 
Chabert's  Disease 

Charcot's  Disease 

Cheadle's  Disease 
Cheiropompholyx 
Chlorosis 

Cholsemia,  Congenital 
Cholera  Nostras 
Cirrhosis  of  Kidney,  Conse-^ 
cutive  J 

Claudication  Intermittente 

CoeHac  Disease  (Gee) 
Corrigan's  Disease 
Cretinism 

Cruveilhier's  Paralysis 
Cyanotic  Kidney 

„        Liver 
Darier's  Disease 
Debove's  Disease 


Trichorrhexis  Nodosa 
Acute  Periencephalitis, 
Typhomania 
Facial  Paralysis 
Electric  Chorea 
Meralgia  Paraesthetica 
Pernicious  Anaemia 
Paroxysmal  Hseinoglobinuria 

Melanuric  Fever 
Paralytic  Food  Poisoning 
Infective  Endocarditis 
Nephritis,  Acute  Tubal 
Modified  Typhus 
Pyrexial  Splenic  Anaemia 
Acute  Fatty  Degeneration 
Labio-Glosso-Laryngeal  Para 

lysis 
Diver's  Paralysis 
Paratyphoid    imposed    upon 
Verruga  Peruana 

=     Anthrax,  Sympathetic 

f  Amyotrophic    Lateral     Scle- 

=  -j       rosis,    also 

(  Locomotor  Arthropathy 

==     Infantile  Scurvy 

=     Dysidrosis 

=     Green  Sickness 

=     Acholuric  Jaundice 

=     Cholerine,  Sporadic  Cholera 

=     Surgical  Kidney 

_  f  Obliterative  Arteritis 

(  Dysbasia  Angio -sclerotica 
=     Acholia  (Cheadle) 
=     Aortic  Eegurgitation 
=     Congenital  Myxcedema 
=     Progressive  Muscular  Atrophy 
=     Passive  Congestion  of  Kidney 
=     Nutmeg  Liver 
=     Keratosis  Follicularis 
=     Splenomegaly 


=  / 


2  i  2 


1830 


484 


SYNONYMS 


Dementia  Precox 
Dengue 

Dercum's  Disease 

Diabetes,  Bronzed 

„         Phosphatic 

Disseminated  Sclerosis 

Dressier' s  Disease 
Duchenne -Aran's  Disease 
Duchenne's  Paralysis 

Duhring's  Disease 

Duke's  or  Filatow's  Disease 
Duroziez'  Disease 

Ebstein's  Disease 

Ehrlich's  Ansemia 
Eichstedt's  Disease 

Endocarditis,  Malignant 

Enterogenous  Cyanosis 

Erb's  Juvenile  Dystrophy 

„     Paralysis 

.,     Syphilitic  Spinal  \ 

Paralysis  J 

Erichsen's  Disease 
Erythema  Infectiosum 
Eulenberg's  Disease 
Fenwick's  Disease 
Fibromatosis  of  Stomach 

Fibrositis  (Gowers) 


Fifth  Disease 
Fordyce's  Disease 


Adolescent  Insanity 

Dandy  Fever 

Breakbone  Fever 

Adiposis  Dolorosa 

Lipomatosis  Neurotica 

Cirrhosis  of  Liver  (with  sugar- 
less Polyuria) 

Phosphaturia  with  Polyuria 
(no  sugar) 

Insular  Sclerosis 

Multiple  Sclerosis 

Paroxysmal  Hemoglobinuria 

Progressive  Muscular  Atrophy 

Pseudo  -hypertrophicParalysis 

Hydroa 

Dermatitis  Herpetiformis 

'  Fourth  Disease  ' 

Congenital  Mitral  Stenosis 

Lymphadenoma  with  Inter- 
mittent Fever 

Aplastic  Anaemia 

Pityriasis  Versicolor 

Endocarditis,  Ulcerative  or 
Infective 

Sulph-hsenioglobingemia 

Progressive  Muscular  Atrophy 
(Juvenile  Type) 

Superior    Brachial    Plexus 
Paralysis 

=     Syphilitic  Spinal  Sclerosis 

=     Traumatic  Neurasthenia 

=     Fifth  Disease 

=     Paramyotonia  Congenita 

=     Primary  Atrophy  of  Stomach 

=     Cirrhosis  of  Stomach 

'  The  state  of  the  fibrous  tissue 
of  the  muscles  which  causes 
muscular  and  tendinous  rheu- 
matism and  perineuritis ' 

(W.G.) 

Erythema  Infectiosum 
Miliary  Cheilitis 

1830 


t 


i 


SYNONYMS 


485 


Fothergill's  Disease 
Friedreich's  Disease 

Frohlich's  Syndrome 

Gastritis 

Gaucher  s  Disease 
Geisbock's  Disease 

General  Paralysis  = 

Gerlier's  Disease 

Gilles  de  la  Tourette's  Disease^ 

Giovanini's  Disease 
Glenard's  Disease  = 

Goldflam's  Disease  = 

1  Grave's  Disease  = 

Griesinger's  Disease  = 
Gruby's  Disease 

Gull's  Disease  = 

Gull-Sutton's  Disease  = 

Haematomyelia  = 

Hallopeau's  Disease  = 

Hallux  Valgus 

,,        Varus  = 

Hammond's  Disease  = 

Harley's  Disease  = 

Hanot's  Disease 
Hayem's  Hypopepsia 


Trigeminal  Neuralgia 
f  Hereditary  Ataxia  and 
\^  Hereditary  Tabes 

Pituitritis    Posterior,    Dys- 
trophia Adiposo-Genitalis 

Gastric  Catarrh 

Familial  Splenic  Anaemia 

Polycythemia,  Splenomegalic 
(  Paretic  Dementia 
}  Dementia  Paralytica 

Vertige  Paralysant 
(  Guinon's   Disease 
\  Impulsive  Tic 

Nodular  Trichosis 

Enteroptosis 

Myasthenia  Gravis 
/  Basedow's  Disease 
J  Exophthalmic  Go;tre 
]  Parsons'  Disease 
(  Parry's  Disease 

Ankylostomiasis 

Alopecia  Areata 

Myxcedema 

Arterio -capillary  Fibrosis 
(  Spinal  Apoplexy 
1  Haemorrhage  into  Cord 

Pyodermatitis  Vegetans 

Bunion 

Pigeon  Toe 

Athetosis 

Paroxysmal  Hemoglobinuria 

Hypertrophic  Biliary  Cirrhosis 

Achylia  Gastrica 


1  The  honour  of  first  describing  Exophthalmic  Goitre  has  been 
claimed  for  at  least  four  modern  physicians  ;  but  the  conjunction 
of  two,  if  not  three  of  its  principal  symptoms  must  have  been 
familiar  to  the  ancients.  For,  in  the  Dictionnaire  Etymologique 
of  Brachet,  I  find  under  Goitre  the  following  illustration  of  the  fact 
that  guitar,  from  which  the  word  is  derived,  came  to  mean  goitre 
as  well  as  throat.  '  Car  on  trouve  son  derive  gutturosus  dans  Ulpien  : 
"  Si  quis  naturd  gutturosus  sit  aut  oculos  eminentes  habeat,  sanus 
videtur."  '  Ulpian  died  a.d.  226,  and  if  sanus  refers  to  the  mind  a 
distinction  from  the  goitre  of  cretinism  would  seem  to  be  implied. 

1830 


486 


SYNONYMS 


Heart,  Fibroid  = 

Heberden's  Disease  = 

Henoch's  Disease  = 

„         Electric  Chorea  == 

Hirschf eld's  Disease  = 

Hirschsprung's  Disease  = 

Hodara's  Disease  = 

Hodgkin's  Disease  = 

Hodgson's  Disease  = 

Huntington's  Chorea  = 

Ichthyosis  = 

Infective  Endocarditis  = 

Jaksch's  Anaemia  = 

Janet's  Disease  = 

Kahler's  Disease  = 

Kaposi's  Disease  = 

Klumpke's  Paralysis  = 

Kopp's  Thymic  Asthma  = 

Korsakoff's  Syndrome  = 

Kiimmel's  Disease  = 

Kussmaul's  Disease  = 

Landouzy-Dejerine  Paralysis  = 

Landry's  Paralysis  = 

Laryngismus  Stridulus  = 

Legal' s  Disease  = 

Leontiasis  Ossea  = 

Leptomeningitis  = 

Lithaemia  (Murchison)  = 


Little's  Disease 
Lobstein's  Cancer 
Maidismus 
Malassez's  Disease 
Marie's  Disease 


Chronic  Myocarditis 

Angina  Pectoris 

Gastro-arthritic  Purpura 
f  Paramyoclonus  Multiplex, 
(  Myoclonia 

Acute  Diabetes 

Idiopathic  Dilalation  of  Colon 

Trichorrhexis  nodosa 

Lymphadenoma  (u.) 

Dilatation  of  Aortic  Arch 

Hereditary  Adult  Chorea 

Xeroderma  Ichthyoides 

Malignant  Endocarditis 

Pseudo-leuksemia  Infantum 

Psychasthenia 

Multiple  Myeloma 

Xeroderma  Pigmentosum 
/Inferior    Brachial    Plexus 
I      Paralysis 

Laryngismus  Stridulus 

Psychosis  Polyneuritica 

Traumatic  Spondylitis 

Periarteritis  Nodosa 
|  Facio-Scapulo-Humeral 
(      Atrophy 

Acute  Ascending  Paralysis 

Spasmodic  Croup 
:     Nasopharyngeal  Headache 

Megalocephaly 

Arachnoiditis 

Uricsemia  (Flint) 

That     appalling     Anglo-Greek 
hybrid,  uricacidsemia,  is  un- 
worthy of  a  learned  profession 
and  should  be  dropped 
=     Spastic  Cerebral  Paraplegia 
=     Retroperitoneal  Sarcoma 

Pellagra 
=     Cystic  Disease  of  Testis 
=     Pulmonary  Osteo-arthropathy 
_/  (also)    Hereditary    Cerebellar 
"  I      Ataxia 

1830 


SYNONYMS 


487 


Measles 
Meniere's  Disease 

Meyer's  Disease 

Miculicz'  Disease 
Miliaria  Rubra 
Millar's  Disease 

Milroy's  Disease 
Moebius'  Disease 

Morphea 

Morton's  Disease 
Morgan's  Disease 
Mumps 

Myasthenia  Gravis 
Myeloemia 
Neumann's  Disease 

Neurasthenia 

Oppenheim's  Disease 
Osier's  Disease 
Osteo  -Arthritis 
Osteomalacia 
Osteopsathyrosis 
Paget' s  Disease 
Parkinson's  Disease 
Paris'  Disease 
Pavor  Nocturnus 

Paranoia 

Pavy's  Disease 
Pick's  Disease 

Potain's  Syndrome 

Pott's  Disease 
Pneumonoconiosis 
Prickly  Heat 

Primary  Spastic  Paraplegia 


=     Morbilli 

=     Labyrinthine  Haemorrhage 
_  (  Hypertrophy   of   Pharyngeal 
~  t      Tonsil 

=     Symmetrical  Lymphoma 
=     Prickly  Heat 
=     Laryngismus  Stridulus 
_  /  Hereditary  (Edema 

I  Meige's  Disease 

(  Recurrent  Third  Nerve  Para- 

t       lysis 
_  (  Circumscribed  Sclerodermia 

(  Keloid  of  Addison 
=     Metatarsalgia 
=     Syringomyelia  plus  Whitlows 
=     Parotitis 

=     Asthenic  Bulbar  Paralysis 
=     Splenomedullary  Leukaemia 
=     Pemphigus  Vegetans 
Spinal    Irritation 
'  Railway  Spine ' 
=     Amyotonia  Congenita 
=     Splenomegalic  Polycythemia 
=     Arthritis,  Osteophytic 
=     Mollities  Ossium 
=     Fragilitas.  Ossium 
=     Osteitis  Deformans 
=     Paralysis  Agitans 
=     Acrodynia 
=     Night  Terrors 
_  f  Delusional  Insanity  or  Mono- 

I       mania 
=     Cyclic  Albuminuria 
=     Pseudo  cirrhosis  Pericarditica 

J  Gastrectasis    with    Dilated 
[      Right  Ventricle 
=     Angular  Curvature 
=     Fibroid  Lung  (from  dust) 
=     Lichen  Tropicus 

Spasmodic  Spinal  Paralysis 
Primary  Lateral  Sclerosis 

1830 


488 


SYNONYMS 


Pseudobulbar  Paralysis 

Psilosis 

Quincke's  Disease 

„         Meningitis 
Raynaud's  Disease 
Recklinghausen's  Disease 
Reclus'  Disease 
Reichmann's  Disease 

Rigg's  Disease 

Ritter's  Disease 
Rivalta's  Disease 
Rotheln 

Rokitansky's  Disease 

Romberg's  Disease 

Roth's  Disease 

Rummo's  Disease 

Sach's  (or  Tay-Sach's)  Disease^ 

St.  Anthony's  Fire 

Savill's  Disease 

Schonlein's  Disease  = 

Schlatter's  Disease  = 

Shingles 

Siderosis  = 

Spasmus  nutans  = 

Spinal  Apoplexy  = 

,,      Irritation  = 

Splenic  Anaemia  (vague)  = 

Spondylose  Rhizomelique 

Status  Thymicus  = 

Still's  Disease  = 

Strachan's  Disease  = 

Striimpel-Marie's  Disease         = 

Syringomyelia  = 


'  Bilateral '  Hemiplegia 

Sprue 

Angio -neurotic  (Edema 

Ventricular  Hydrocephalus 

Symmetrical  Gangrene 

Pigmentary  Fibromatosis 

Cystic  Disease  of  Mamma 

Gastro-Succorrhoea 
f  Pyorrhoea  Alveolaris 
t  Fauchard's  Disease 
f  Dermatitis   Exfoliativa    Neo- 
V.      natorum 

Actinomycosis 

Rubella  or  German  Measles 

Rose  Rash 
f  Acute  Yellow  Atrophy  of  the 
I      Liver 

Progressive  Facial  Paralysis 

Meralgia  Paraesthetica 

Cardioptosis 

Amaurotic  Family  Idiocy 

Erysipelas 

Epidemic  Eczema 

Peliosis  Rheumatica 

Inflammation    of    Tibial 
Tuberosity 

Herpes  Zoster 
|  Pneumonoconiosis  (from  iron 
l       dust) 

Gyrospasm,  Nodding  Spasm 

Hsematomyelia 

Neurasthenia 

Anaemia,  Splenomegalic 
(  Spondylitis  Deformans,  Pro- 
1.      gressive 

Status  Lymphaticus 

Arthritis,  Splenomegalic 

Multiple  Neuritis 
|  Spondylose    Rhizomelique 
(       (painless  form) 

Hydrorrhachis  Interna 

1830 


SYNONYMS 


489 


Thomsen's  Disease 
Tic  Convulsif 
Tooth's  Paralysis 
Trousseau's  Disease 
Ulerythema  Centrifugum 
Uncinariasis 
Undulant  Fever 

Unverricht's  Disease 

Vagabond's  Disease 

Vaquez's  Disease 

Vincent's  Angina 

Weil's  Disease 
Weir-Mitchell's  Disease 

Werdning-Hofmann  Atrophy 

Werlhof's  Disease 
White's  Disease 
WinkePs  Disease 

Woillez'  Disease 

Woolsorters'  Disease 

Xanthoma 

Xeroderma 

Zona 


=     Myotonia  Congenita 
=     Habit  Spasm 

=     Hereditary  Peroneal  Atrophy 
=     Gastric  Vertigo 
=     Lupus  Erythematosus 
:     Ankylostomiasis 
.Malta  Fever 
(  Familial  Myotony 
I  Myoclonus  Epilepticus 

Patchy  Phthiriasis 
i  Osier's   Disease 
I  Geisbock's  Disease 
I  Membranous    Pharyngitis 
I       (with   Bacillus  Fusiformis) 
Acute  Infective  Jaundice 
Erythromelalgia 
(  Progressive  Muscular  Atrophy 
t       of  Infants 
Acute  Purpura  Hemorrhagica 
Keratosis  FoUicularis 
Infantile  Hemoglobinuria 
f  Acute  Idiopathic  Pulmonary 
I       Congestion 
Pulmonary  Anthrax 
Vitiligoidea 
Keratosis  Pilaris 
Herpes  Zoster 


1830 


INDEX 


Abadie's  eyelid-sign,  405 

tendon  sign,  202 
Abderhalden's  test,  933 
Abdomen  : 

accordion,  821 

auscultation  of,  1788 

enlarged  veins  of,  828 

palpation  of,  1608 

percussion  of,  1695 

prominent,  819 

retracted,  823 

with  inspiration,  824 

rigid,  827 
Abdominal  bands,  1637 

tumours,  1615 
Abnormal  pulsation,  284-289 
Absent  breathing  sounds,  1718 
Abulia,  1268 
Accordion  abdomen,  821 
Accommodation  reflex,  515 
Accoucheur's  hand,  890,  1432 
Acetone  in  blood,  1481 

test,  966 
Acetonuria,  1018 
Acid  risings,  220 
Acid-resisting  *bacteria,  1499 
Acidity  of  stomach,  1122 
Acidosis,  1017 
Actinomyces,  1179,  1577 
Active  occupation,  24 
Acute  diseases,  52 
Adductor  paralysis,  705,  706 
Adolescence,  18 
Adults,  diseases  of,  19 
JSgophony,  1734 
Aerophagia,  1080 
Age,  14 

estimation  of,  14 


Ageusia,  673 
Agglutination,  1484 
Agoraphobia,  1280 
Agraphia,  1259 
Ahlf eld's  sign,  1653 
Air  hunger,  1221 
Akinesia  algera,  195 
Albumen  test,  951 
Albuminuria,  1004 
postural,  1005 
Albumosuria,  954,  1007 
Alcoholism,  history  of,  39 
Alexia,  1241 

Algesise,  188 

Alkalinitv  of  blood,  1478 

Allis's  sign,  849 

Allocheiria,  205 

Allocinesia,  1355 

Allorrhythmia,  258 

Alternating  emotions,  1275 

Amaurosis,  565 

Amblyopia,  562 
crossed,  563 

Amenorrhoea,  74 

Amimia,  1248 

Amnesia,  1265 

Amoebae,  1188,  1558 

Amphoric  breathing,  1723 
resonance,  1676 

Amphoteric  urine,  980 

Amusia,  1250 

Amyloid  casts,  1072 

Amyosthenia,  1352 

Anacrotic  pulse,  261 
wave,  277 

Ansemia,  385,  1829 

Anaesthesia,  202 
dissociated,  203 

Ab-An 


492 


INDEX 


Anaesthesia : 

dolorosa,  196 

muscular,  208 

stocking,  202 

tendinous,  208 
Anal  swellings,  840 
Analgesia,  189 

deep,  190 
Anarthria,  1239 
Anasarca,  335 
Aneurysm,  mimic,  284 
Aneurysmal  bruit,  1784 
Angular  curvature,  815 
Angulus  Ludovici,  745 
Anidrosis,  314 
Aniline  reaction.  1485 
Anisocoria,  501 
Anisocytosis,  1452 
Ankle  clonus,  1390 
Anorexia,  69 
Anosmia,  588 
Anthropophobia,  1280 
Anuria,  945 
Anxietas,  413 
Anxiety,  precordial,  221 
Aortic  tug,  713 
Apex  of  heart,  1597 
lung,  1679 
Aphasia,  1240-1242 

auditory,  1240 

motor  1241 

visual,  1240 
Aphemia,  1243 
Aphonia,  1227 
Aphthongia,  664 
Appetite,  diminished,  69 

increased,  68 

morbid,  70 
Apple-j elly  nodules,  354 
Apraxia,  1245 
Aprosexia,  1267 
Arcus  senilis,  466 
Argyll-Robertson  pupil,  516 
Arm  : 

oedema  of,  872 

shortened,  881 
Arrhythmia,  258 
Arterial  murmurs,  1778 

tension,  271-274 
Artery  : 

atheromatous,  266 

tortuous,  266 


Articulation,  paralysis  of,  1239 

Ascent,  line  of,  276 

Ascites,  1704,  1829 

Aspergillus,  1178 

Aspirated  fluid  : 

abdomen,  787-797 
chest,  777,  786 
spine,  798-804 

Astasia  abasia,  1301 

Astereognosis,  207 

Asymbolia,  1247 

Asymmetry  of  skull,  358 

Ataxia,  1303 

Atheroma,  266 

Athetosis,  1415 

Atopognosis,  210 

Auenbrugger's  sign,  820 

Aufrecht's  sign,  1719 

Auricular  fibrillation,  259 
flutter,  1770 

Auscultation  methods,  1715 
of  abdomen,  1788-1799 
arteries,  1778-1784 
bones,  1801 
buccal  cavity,  1786 
head,  1785 
heart,  1745-1771 
joints,  1802 
lungs,  1716-1743 
oesophagus,  1787 
veins,  1772-1777 

Auscultatory  percussion,  1711 

Autophonia,  437 

Autumn  diseases,  1807 

Avelli's  syndrome,  1316 

Axillary  glands  enlarged,  874 
swellings,  873 


Babes'  sign,  177 
Babinski's  fan  sign,  1398 
leg  phenomenon,  1399 
reflex,  1373 
Bacelli's  sign,  1737 
Bacilli,  1521-1527 
acid-fast,  1499 
in  sputa,  1139,  1185 
stools,  1108 
urine,  1060 
vomit,  1136 
varieties  of,  1521 

An-Ba 


INDEX 


493 


Back  : 

stiff,  S06 

swellings  on,  810 
Bacteria,  1495-1556 
Baldness,  378,  379 
Ballooning  of  rectum,  1641 
Ballottement,  1652 
Bamberger's  sign,  205 
Bands,  abdominal,  1637 
Barany's  test,  491 
Bard's  sign,  490 
Barrel-shaped  chest,  744 
Base-line,  undulating,  276 
Basophilia,  1467 
Bastedo's  sign,  181 
Bearing- down  feeling,  228 
Beau's  bines,  907 
Beaume's  sign,  110 
Bechterew's  reflex,  1377a 

deep  reflex,  14C0 

pupil  reflex,  518 
Bechterew's  sign,  202 
Bell's  phenomenon,  487 
Bell  sound,  1798 
Belly,  pendulous,  819 
Benedikt's  syndrome,  134) 
Berger's  sign,  506 
Biermer's  sign,  1U87 
Biernacki's  sign,  216 
Bilharzia,  1108 
Biot's  breathing,  1212 
Bird's  sign,  1667 
Bite,  attempts  to,  597 
Bittorf's  reaction,  183 
Black-currant  rash,  332 
Bleeding  : 

from  ears,  426 
gums,  620 
nose,  586 
Blepharospasm,  456 
Blinking,  456 
Blood,  the,  1448-1494 

coagulation  of,  1486 

freezing  point  of,  1487 

in  sputa,  1149 
stools,  1096 
urine,  982,  1000 
vomit,  1121 

on  aspiration,  781 

pressure,  271 

specific  gravity  of,  1469 
Blow,  history  of,  36 


'  Blue  Bottom,'  324 
Blue  oedema,  337 
Blumberg's  sign,  182 
Boas'  point,  186 
meal,  1111 
Boat-shaped  abdomen,  823 
Bolognini's  symptom,  1620 
Bone  : 

fragility  of,  847 

nodes  of,  845,  846 

swellings  of,  843 
Borborygmi,  1080 

silenced,  1791 
Bowels,  state  of,  1077-1084 
Bowler's  side,  113 
Bradycardia,  242 
Bradylalia,  1254 
Branchial  fistula,  726 
Breast,  the,  769-776 
Breath 

alliaceous,  1201 

bitter-almond,  1200 

cold,  292 

foul,  1202 

short,  1221 

sweet,  1199 
Breathing  : 

abdominal,  1219 

amphoric,  1723 

Biot's,  1212 

bronchial,  1721 

cavernous,  1722 

Cheyne-Stokes',  1214 

cog-wheel,  1717 

cyclical,  1213 

Hosslen's,  1211 

indeterminate,  1721 

inverted,  1217 

irregular,  1212 

jerky,  1210 

puerile,  1716 

rapid,  1223 

shaUow,  1203 

sighing,  1208 

slow,  1205 

stertorous,  1206 

stridulous,  1207 

suffocative,  1220 

thoracic,  1218 

wavy,  1717 

weak,  1718 
*  Breites  Bcin,'  856 

Ba-Br 


494 


INDEX 


Brenner's  sign,  1800 
Brieger's  reaction,  1489 
Brissaud's  reflex,  1379 
Bronchophony,  1735 
Brudzenski's  signs,  1401,  14(  2 
Bruit,  aneurysmal,  1784 
d'airain,  1677 
de  diable,  1776 
de  drapeau,  1728 
de  moulin,  1768 
de  rappel,  1762 
Bryson's  sign,  782 
Buccal  membrane,  612 

Koplik's  spots  on,  618 
papules  on,  614 
petechia  on,  616 
pigment  on,  617 
ulcers  on,  613 
vesicles  on,  615 
Bulbo- cavernous  reflex,  1368 
Bulging  of  chest,  748-75 1 
hypochondrium,  752 
Bulimia,  68 
Bullae,  348 

black,  348 
Bulldog  head,  358 
Bullock's  liver  crusts,  354 
Bumke's  pupil,  523 
Burton's  line,  622 
Butterfly  nose,  568 


Cachexia,  311 
Cacogeusia,  675 
Calculi,  urinary,  1045,  1077 
Calmette's  reaction,  1816 
Cammidge's  test,  1160 
Camptodactylia,  896,  897 
Cancer  particles,  1170 
Caput  Medusae,  836 
Cardiac  dullness,  1689-1694 
Cardialgia,  220 
Carotid  murmur,  1779 
Carotids,  throbbing,  721 
Carphology,  1417 
Casts  : 

bronchial,  1155 

rectal,  1097 

urinary,  1064-1073 
Catch  in  breath,  151 
Caterpillar  rash,  346 


Cathelin's  separator,  971 
Catisophobia,  1280 
Cavernous  breathing,  1722 
Cell-colour  ratio,  14^0 
Cerebro-spinal  fluid,  799-804 
Cervical  gland  areas,  731 

glands,  enlarged,  731 
Change     of     percussion      note, 

1682 
Change  of  temper,  1277 
Charcot's  oedema,  337 

joint,  914 
Charcot- Leyden  crystals,  1166 
Cheek,  flapping,  400 
Chemosis,  486 
Chest : 

barrel-shaped,  744 

bulging  of,  748-751 

enlarged  veins  of,  768 

flat,  740 

flattened  locally,  757 

foveated,  755 

funnel,  755 

immobile,  767 

palpation  of,  1586-1607! 

percussion  of,  1657-1694 

pigeon,  742 

pterygoid,  741 

red  zone  on,  747 

regions  of,  737 

'  rosary,'  746 

shrunken,  754  ] 

walls,  739 

zonal  constriction  of,  743 
Cheyne-Stokes'  breathing,  1214 
Childhood,  diseases  of,  17 
Children,  examination  of,  15 
Chills,  239 

Chimney-sweep's  cancer,  929 
Choked  disc,  538 
Cholestearin,  1054,  1483 
Choline  in  blood,  1482 
Chorea  phenomenon,  1389 
Choroiditis,  543 
Choroid  tubercles,  542 
Chromatopsia,  549 
Chromocystoscopy,  948 
Chronic  diseases,  54 
Chvostek's  phenomenon,  1433 
Cilio- spinal  reflex,  522 
Cinder-sifting  mobility,  1622 
Clammy  skin,  315 

Br-Cl 


INDEX 


495 


Clark's  "sign,  1696 
Clasp-knife  rigidity,  1420 
Claudication,  1292 
Claustrophobia,  1280 
Clavus,  173 
Clavicle,  rotundity  of  one,  715 

swelling  above,  714 
Claw  foot,  858 
h*     hand,  887 
Cliquetis  metallique,  1767 
Clonic  spasms,  1407 
Clonus,  ankle,  1390 

patella,  1388 
Clots  in  urine,  1003 
Coagulation  period,  1486 
Cobbler's  chest,  755 
Cocci,  varieties  of,  1501 
Coffee-ground  vomit,  1121 
Cogwheel  inspiration,  1717 
Coin  sound,  1662,  1677 
Cold  breath,  292 
Cold,  subjective,  239 
CoUapse,  235,  1829 
Colic,  122 
Colon  test,  1707 
Colour  index,  1460 
Coma,  64,  1829 
Coma  vigil,  63 
Compound  symptoms,  1829 
Concretions,  1102 
Conduct,  deterioration  of,  1279 
Condylomata,  355 
Congenital  affections,  23 
Conjunctiva,  476-486 
Conjunctival  reaction,  470 
Consciousness,  loss  of,  65 

momentary,  66 
Consensual  reflex,  510 
Constipation,  1078 
Contacts,  49 
Contagion,  45 
Contractures,  active,  1420 

passive,  1421 
Convulsions,  1414 
Co-ordination,  1303 
Coprolalia,  1253 
Cor  mobile,  1602 
Cornea,  hazy,  465 

opacities  on,  468 

ulcers  on,  469 
Corneal  reflex,  470 
Corona  veneris,  346 


Cough,  1192-1197 

barking,  1194 

brassy,  1194 

dry,  1193 

hacking,  1193 

hoarse,  1194 

inability  to,  1197 

paroxysmal,  1195 
Coughing,  impulse  on,  1619 
Cracked-pot  sound,  1661,  1670 
abdominal, 
1703 
Crackle,  dry,  1728 
Cramps,  1418 
Craniotabes,  375 
Crepitation,  1731 

cardio-pulmonary,  1771 ' 

joint,  1802 
Crepitus,  844 

Cri  hydrencephalique,  1232 
Crichton-Browne's  sign,  1407 
Crisis,  termination  by,  303 
Cross  heredity,  30 
Crossed  adductor  jerk,  1385 
Crossed  amblyopia.  578 
Crossed-leg  deformity,  855 
Crossed  paralysis,  1338 
Crural  monoplegia,  1331 
Crusts,  352 
Cry,  infant's,  1233 
Cryoscopy  of  urine,  1039 
Cupped  disc,  540 
Currant  test,  1124 
Curschmann's  spirals,  1165 
Curvature  of  spine  : 

angular,  815 

anterior,  812 

lateral,  814 

posterior,  813 
Cutaneous  reflexes,  1360 
Cyanosis,  396 
Cycle,  cardiac,  1745 
Cyphosis,  812 
Cystoscope,  946 


Damoiseatj's  line,  1664 
Davidsohn's  sign,  603 
Day  restlessness,  56 

time  of,  1803 
Deafness,  433 
Debility,  233,  1829 

Cl-De 


496 


INDEX 


Decubitus,  1281-1289 
Deehan's  reaction,  1823 
Dcetyen's  bodies,  145G 
Defaecation,  painful,  1082 
Deglutition  rales,  1731 
Delirium,  1271 

cordis,  1766 
Delusions,  1270 
Demarquay's  sign,  720 
Dementia,  1263 
Dentition,  633-635 

early,  634 
Depression,  1274 
Dermatographia,  325-326 
Descent,  line  of,  276 
Desmoid  reaction,  969 
D'Espine's  sign,  1738 
Desquamation,  342 
Deviation,  conjugate,  496 
Dextrocardia,  284,  1600 
Diadococinesia,  1332 
Diagnosis,  art  of,  1 
Diapedesis,  530 
Diaphragm  : 

high,  764 

low,  765 

phenomenon,  766 
Diarrhoea,  1079 
Diazo-reaction,  965,  1033 
Dietl's  crisis,  143 
Digital  examination,  1643 
Digiti  mortui,  871 
Digitus  Hippocraticus,  895 
Diplegia,  1348 
Diplococci,  1512 
Diplopia,  545 

monocular,  546 
Dipping,  1612 
Discharge,  vaginal  : 

offensive,  82 

purulent,  81 

sanguineous,  81 

white,  80 
Distoma  pulmonale,  1175 
Dittrich's  plugs,  1159 
Dizziness,  231 
Double  jog,  1604 

knock,  1714 

vision,  545 
Douglas's  pouch,  1645 
Douleur  signal,  184 
Dragged  foot,  1299 


Dribbling,  592 
Drowsiness,  61 
Drug  diagnosis,  1826 
Drug  eruptions,  344,  353 
Drumstick  fingers,  895 
Dry  crackle,  1728 

skin,  314 
Duckworth's  sign,  1215 
Dullness  : 

abdominal,  1702 

apical,  1666 

cardiac,  1689-1694 

chest,  1664-1669 

intellectual,  1262 

liver,  1697 

lung,  1664-1669 
Dupuytren's  contraction,  891 
Duration,  51-54 
Duroziez'  murmur,  1780 
Dysacusis,  435 
Dysbasia,  1292 
Dysdiadococinesia,  1333 
Dysmenorrhea,  75 

membranous,  83 
Dyspareunia  78 
Dyspepsia,  1584 
Dysphagia,  693 
Dyspnoea,  1221-1225 

on  exertion,  1222 

paroxysmal,  1225 
Dysuria,  942 


Earache,  95 
Ears  : 

bleeding,  426 

discharging,  428 

gangrenous,  424 

growths  in,  425 

livid,  422 

malformed,  418 

swollen,  423 

waxy,  421 
Earthy  skin,  390 
Ecchymosis,  332 
Echolalia,  1252 
Echophony,  1739 
Eggshell  bodies,  1063 
crackling,  844 
Egg-yellow  reaction,  1034 
Ehrlich's  reaction,  965,  1033 
De-Eh 


INDEX 


497 


Elastic  fibres  : 

in  sputa,  1140-1169 
urine,  .1051 
Elbow- jerk,  1392 
Electrical  reactions,  1434-1447 
Ellis's  line,  1004 
Embryocardia.  1758 
Emotions,  1272-1278 

alternating,  1275 
Emphysema,  interstitial,  338 
Emprosthotonos,  1425 
Enophthalnios,  493 
Entassement  vertebrale,  816 
Enuresis,  939 
Eosinopenia,  1465 
Eosinophile  cells  in  sputa,  1173 
Eosinophilia,  1464 
Epidemic  diseases,  43 
Epigastric  pulsation,  287 
Epiphora,  480 
Epistaxis,  586 
Episternal  retraction,  718 
Erb's  point,  1447 

sign,  1444,  1664 
Erben's  phenomenon,  243 
Erector  spinae,  rigid,  811 
Erichsen's  sign,  165 
Eructations,  1122 
Eruption  periods,  52 
Erythema,  344 
Esbach's  test,  952 
Escherich's  test,  1820 
Eustace  Smith  sign,  1777 
Ewart's  sign,  753 
Exaltation,  1273 
Excitement,  1273 
Exophthalmos,  492 
Exotic  diseases,  1810 
Expansion,  belated,  767 
Expectoration,  1141 
Expiration,  prolonged,  1720 
Explanation  of  Regions,  737 
Expression  : 

anxious,  413 

leonine,  412 

threatening,  414 

vacant,  411 
Extremities,  cold,  870 
Eyeballs,  487-500 
Eyelids  : 

blinking,  456 

blue  secretion  from,  460 


2  K 


Eyelids : 

crusted  edges,  460 

dark,  454 

'Irooping,  4~>  7 

ecchymosed,  452 

open,  459 

sluggish  re-oponing  of,  45f 

swellings  on,  465 

swollen,  453 
Eyes,  bloodshot,  483 

bright,  482 

discharge  from,   181 

dry,  477 

ecchymosed,  484 

fixed,  488 

oscillating,  489 

protruding,  492 

'  sloppy,'  485 

sunken,  493 

watery,  478 


Face  : 

cyanosed,  396 

flushed,  387,  388 

'  full-moon,'  358 

grey,  389 

lemon,  391 

pallid,  385,  386 

pinched,  401 

sallow,  390 

swollen,  403 

twitchings  of,  405 

unequal,  399 

yeUow,  392-395 
Facial  paralysis,  1312 

ulceration,  398 
Facies,  407 
Faecal  vomiting,  1137 
Faeces  : 

flattened,  1086 

pale,  1089 

pipe-like,  1087 

in  urine,  1040 

(see  Stools) 
Faintness,  230 
Fallacy  of  antecedent  disease,  4 

concurrent  disease,  5 

malingering,  11 

obsession,  6 

perspective,  7 

suggestion,  3 

El-Fa 


498 


INDEX 


Fallacy  of   the   personal    equa- 
tion, 9 

transferred  pain,  10 

variations,  within  the  nor- 
mal, 8 
Falling-drop  sound,  1729 
Familial  diseases,  31 
Faradisation,  1435 
Fat  crystals  in  sputa,  1167 

development  of,  308 

globules  in  urine,  1050 

in  blood,  1480 

in  stools,  1100 
Fauces  : 

reddened,  677 

swollen,  678 

white  patches  on,  679 
Fear  of  space,  1280 
Fears,  unreasoning,  1280 
Features,  thickened,  402 
Females,  diseases  of,  13 
Femoral  murmur,  1780 
Festinant  gait,  1300 
Fever,  295-298 
Fibrinuria,  1009 
Field  of  vision,  contracted,  543 
Filaria,  1560 
Filtrable  viruses,  1500 
Fingers  : 

bent,  898 

clubbed,  895 

drumstick,  895 

pads  on,  901 

red  tips  to,  900 

swollen,  899 
Fissures  at  mouth,  611 
Fistel-symptom,  439 
Fistula  : 

branchial,  726 

umbilical,  835 
Flankengang,  1302 
Flapping  cheek,  400 
Flashes,  subjective,  559 
Flatulence,  1080 
Flora's  reaction,  1438 
Fluid: 

aspirated,  779-805 

test  for  gastrectasis,  1731 
Flushed  face,  3$7 
Flushings,  378 
Foam  at  mouth,  595 
Foetal  heart,  1783 


Foetus,  age  of,  1656 
Folio  de  Pourquoi,  1251 
Fontanelles  : 

bulging,  369 

depressed,  370 

enlarged,  372 

late  in  closing,  371 
Foot: 

claw,  858 

cold,  870 

dragged,  1298 

enlarged,  857 

everted,  859 

gangrenous,  868 

pad  on  dorsum  of,  869 

perforating  ulcer  of,  866 

swollen,  863,  864 

turned  in,  860 
'  Foot  drop,'  1324 
Forchheimer's  sign,  640 
Formication,  218 
Fortification  figures,  559 
Foveated  chest,  755 
Frsenal  ulcer,  657 
Fragilitas  ossium,  847 
Francke's  symptom,  175 
Freezing  point,  1487 
Fremissement  cataire,  1592 
Fremitus  : 

friction,  1591 

rhonchal,  1590 

tactile,  1588 

xiphoid,  1638 
Friction,  abdominal,  1790 

pericardial,  1769 

pleural,  1740 

pleuro -pericardial,  1771 

shoulder,  1740 
Friedreich's  sign,  1688 
Frimadeau's  sign,  1813 
Frontalis  symptom,  406  J 
'  Full-moon '  face,  358 
Fullness,  feeling  of,  226 
Funnel-breast,  755 


Gaertner's   vein  phenomenon, 

878 
Gait,  1290-1302 
Gall-bladder,  enlarged,  1633 
Galloping  rhythm,  1764 
Galton's  law,  28 

Fa-Ga 


INDEX 


499 


« lalvanie  curront,  1436 
GangrenOj  351 

<  ran  liner-Brown's  sign,  447 
( lard's  sign,  560 
( Garland's  line,  1664 
Garrod's  finger  pads,  901 
Garrulitas  vulva?,  84 
Gasoous  test,  1706,  1707.  L7€5 
Gastric  motility,  1124 
Gastro-diaphany,  691 
Gastroscopy,  690 
Geigel's  reflex,  1369 
Gelle's  test,  450 
Genitals,  921-935 
Genu  retrorsum,  918 
Gerhardt's  sign,  1686 
Ghilarducci's  reaction,  1442 
Ghosts  in  blood,  1458 
Giddiness,  231 
Gifford's  reflex,  521 
Gilbert's  sign,  976 
Girdle  sensation,  222 
Glands  and  areas  : 

axillary,  874 

cervical,  731 

epitrochlear,  877 

inguinal,  893 

lumbar,  1639 

mesenteric,  1639 

occipital,  732 

parotid,  728 

pras-auricular,  404 

submaxillary,  730 

supraclavicular,  731 
Glasgow's  sign,  1782 
Globus  hystericus,  226 
Glucose  test,  949 
Glycogenic  fluid,  795 

reaction,  1477 
Glycosuria,  949,  1012 
Gmelin's  test,  958 
Gonococci,  1059,  1514 
Gooseberry-skin  sputa,  1157 
Goose-flesh,  340 
Gould's  sign,  365 
Gower's  sien,  511 
Gradenigo's  sign,  1311 
Graefe's  symptom,  462 
Gram's  stain,  1496 
Granular  cells,  1455 
Grasp,  weak,  1330 
Grasset's  sign,  1403 


Grimaces,  415 
Grocco's  test,  334 

triangle,  1669 
Groin,  swellings  in,  838 
Griinbaum's  test,  274 
Guarnieri  bodies,  158^ 
Guinea-pig  test,  1821 
Gums  : 

bleeding,  620 

coloured  line  on,  622 

pale,  621 

spongy,  620 

swelling  on,  623 
Gunzberg's  sign,  1701 
Gurgling,  1725 


H -shaped  bruise,  332 
Haemacytozoa,  1562 
Hsematemesis,  1121 
Haematoma,  332,  420 
Haematoporphyrin,  1002 
Haematuria,  1000 
Haemoconiosis,  1468 
Haemoglobin,  1470,  1471 

free,  1472 
Haemoglobinuria,  1091 
Haemoptysis,  1149 
Hair  : 

beaded,  383 

exclamation-point,  381 

matted,  382 

thin,  378 

weak,  377 
Hallux  erectus,  867 
Hallucinations,  1269 
Hand  : 

accoucheur's,  890 

ape,  888 

claw,  887 

deflected,  883 

dropped,  1323 

enlarged,  884 

paralysis  of,  1330 

preacher's,  889 

spade,  886 

swollen,  885 

trident,  898 
Handwriting,  1256 
Haphalgesia,  194 
Harrison's  sulcus,  743 
Haygarth's  nodes,  893 

K  2  Ga-Ha 


500 


INDEX 


Head: 

nodding,  363 

cede  liatous,  366 

oscillating,  362 

retracted,  361 

roUing,  360 

shape  of,  358 

size  of,  358 

swellings  on,  359 

veins  of,  367 

voluminous,  360 
Headache  : 

frontal,  89 

general,  93 

helmet,  92 

occipital,  90 

of  vertex,  92 

unilateral,  91 
Hearing,  431-439 

exalted,  434 

impaired,  433 
Heart : 

apex  of,  1597 

auscultation  of,  1745 

irregular,  1766 

murmurs,  1746 

percussion  of,  1689-1694 

sounds,  altered,  1754 
Heart's  pauses,  1757 
Heartburn,  220 
Heat,  subjective,  223 
Heberden's  nodes,  892 
Hebetude,  1262 
Hectic,  299,  1829 
Heel-jar,  136 
Hegar's  sign,  1651 
Heilbronner's  thigh,  856 
Heller's  test,  962 
Helmet  headache,  92 
Hemeralopia,  552 
Hemianesthesia,  204 
Hemianosmia,  588 
Hemiatrophy,  399 
Hemigeusia,  673 
Hemihypertrophy,  399 
Hemiopia,   547 

altitudinal,  547 
Hemiplegia,  1335-1345 
Hen-cluck  stertor,  1206 
Hereditary  diseases,  29 
Heredity,  cross,  30 
Herpes  labialis,  609 


Hertzel's  sign,  275 
Heterocinesia,  1353 
Hiccough,  1416 
High-stepping  gait,  1299 
Hippuric  acid,  1027 
Hippus,  512 

Hirschberg's  reflex,  1378 
History,  28 

of  a  bite,  35 
alcoholism,  39 
blow,  or  fall,  36 
dietetic  error,  58 
former  illness,  34 
infection,  33 
previous  attack,  32 
residence  abroad, 
rigor, 
strain,  37 
Hooklets  in  urine,  1062 
sputa,  1172 
Hoover's  sign,  1397 
Hot-cross  bun  head,  358 
Hour-glass  head,  358 
Howship- Romberg  sign,  132 
Huchard's  symptom,  1673 
Hunger  pain,  117,  148 
Hutchinson's  mask,  188 

teeth,  631 
Hyaline  cells,  1457 
Hydrocele  of  Nuck,  931 
Hydremia,  1470 
Hydrochloric  acid,  test  for,  1110 
Hyperacusis,  434 
Hyperesthesia,  201 
Hyperalgesia,  191 
muscular,  192 
Hyperchlorhydria,  112C 
Hyperidrosis,  316 
Hyperinosis,  1475 
Hyperosmia,  589 
Hyperpyrexia,  297,  1829 
Hyper-resonance,  1673 
Hypertrichosis,  380 
Hypertrophy  of  heart,  1829 
Hypinosis,  1476 
Hypochlorhydria,  1127 
Hypochondrium  : 
bulging  of,  752 
tenderness  of,  160,  161 
Hypogastric  reflex,  1397 

tenderness,  166 
Hypotonia,  muscular,  1349 

He-Hy 


INDEX 


501 


Iliac  tenderness,  164 
Illumination,  oral,  602 
Illusions,  1269 
Impotence,  927 
Impulse  : 

heart's,  1597 
on  coughing,  1619 
Incontinence  of  faeces,  1084 
urine,  938 
Incoordination,  1303 
Incubation  periods,  52 
India-rubber-ball  sound,  1724 
Indican,  1022 
Indol,  1098 

Infancy,  diseases  of,  16 
Infection  44 

exposure  to,  49 
by  carriers,  47 
clothing,  46 
Inguinal  glands,  enlarged,  862 
Inoculation  test,  804 
Inosite  in  urine,  1016 
Insomnia,  57 
Intellect,  1261 
Intention  tremor,  1410 
Interspaces  : 

bulging,  759 
retracted,  760 
Intestinal  concretions,  1102 

obstruction,  1078 
Invasion   periods,  52 
Iridodonesis,  507 
Iris,  trembling,  507 
Irregular  heart,  1766 
Irritability,  1278 
Irritant-poisoning,  1829 
Isolysin  in  blood,  1488 
Itching,  218 


Jacquehier's  sign,  932 
Jactitation,  1411 
Jadelot's  traits,  408 
Janet's  test,  200 
Jaundice,  392 
Jaw  : 

closed,  1424 

reflex,  1395 

swohen,  623 
Jaworski's  kernels,  1138 

test,  1794 
Jendrassik's  reinforcement,  1358 


Jerking,  1411 

Jerks,  knee,   1382-1384 

Joint : 

Charcot's,  914 
contracted,  917 
creaking,  916 
distorted,  917 
stiff,  915 
suppurating,  919 
swollen,  914 

Jolly's  reaction,  1439 

Jugular  : 

distended,  722,  724 
empty,  723 

Justus' "test,  1493 


Reeling's  test,  1111 
Kellock's  sign,  1681 
Keratitis,  467 
Kernig's  sign,  1422 
Ketonuria,  1019 
Kidney,  movable,  1613 
Kinesthetic  sense,  208 
Kink  sign,  185 
Knee,  915 

over-extended,  918 
Knee-jerk,  1382 

choreic,  1389 

clonus,  1388 
Kocher's  sign,  463 
Koilonychia,  910 
Koplik's  spots,  618 

stigma,  894 
Kussmaul's  sign,  724 


Labia,  swelling  of,  931 

Lacrymation,  478 

Lactic  acid  in  vomit,  1128 

tests,  1111,  1112 
Lactose  in  urine,  1015 
Laevulosuria,  1013 
Lagophthalmos,  459 
Lake  blood,  1472 
Lapping  murmur,  1763 
Laryngoscope,  694  \ 

Larynx  : 

growths  of,  697 

membranes  on,  701 

paralyses  of,  702-708 

spasm  of,  .698 

Il-La 


502 


INDEX 


Larynx : 

stenosis  of,  695 
swellings  of,  699 
ulcers  of,  695 
Lasegue's  symptom,  1351 
Lassitude,  233 
Laughter,  1234 
Legs  : 

curved,  854 
false  shortening,  853 
lengthened,  851 
'  scissor,'  855 
shortened,  852,  853 
swollen,  863,  864 
Leishman's  bodies,  1572 
Lemon  complexion,  391 
Leopard's  growl,  1207 
Lesieur's  sign,  1664 
Leucin,  1055 
Leucocytosis,  1461 
Leucopenia,  1462 
Leucorrhoea,  80 
Limbs,  inspection  of,  841-393 
Limp,  intermittent,  1292 
Linese  albicantes,  822 
Lip,  tapir,  638 
Lips  : 

'  blubber,'  608 
fissured,  611 
herpes  on,  609 
livid,  396 

local  swelling  on,  607 
pallid,  385 
swollen,  606 
ulcerated,  610 
Litton' s  sign,  766 
Live  blood,  1403 
Liver  : 

circumscribed    swelling   on, 

1630 
depressed,  1631 
enlarged,  1627 
nodular,  1629 
pulsating,  286 
raised,  1699 
smooth,  1623 
/  tender,  160 

Liver  dullness  : 
altered,  1697 
diminished,  1696 
increased,  1698 
examination  of,  1611 


Lividity,  396 

Localisation  of  reflexes,  1358 
Loewi's  symptom,  524 
Loins  : 

oedematous,  808 

tender,  157 
Lordosis,  813 
Lorenz'  sign,  806 
Luetin  test,  1824 
Lumbar  glands,  1639 

oedema,  808 

paracentesis,  793-804 

prominence,  897 

stiffness,  806 
Lungs  : 

apex  of,  1679 

auscultation   of,    1716-1743 

percussion  of,  1664-1688 
Lymphatic  areas  (see  Glands) 
Lymphatic  glands,  enlarged  (see 

Glands) 
Lymphocytosis,  1463 
Lysis,  termination  by,  304 

McBurney's  point,  180 
MacCormac's  reflex,  1384 
Macewen's  sign,  1710 
Macrocytes,  1453 
Macropia,  564 
Maculae,  345 
MacWilliam's  test,  951 
Madelung's  deformity,  882 
Magnan's  sign,  217 
Main  bote,  887 
Main-en-griffe,  310,  887 
Mal-coordination,  1303 
Males,  diseases  of,  12 
Mamma  : 

pigmented,  775 

swellings  of,  772 
Mann's  sign,  499 
Mannkopf's  sign,  154 
Manus  valga,  832 
Masque  des  femmes  enceintes,  324 
Masque  tabetique,  188 
Mast-cells,  146/ 
Meal,  Boas'  test,  1111 
Meatus,  bleeding  from,  426 

discharge  from,  428 

swelling  in,  427 
Megaloblasts,  1454 
Melsena,  1096 

La-Me 


INDEX 


503 


MiIan.Tmia,  1 17  1 
Melancholy,  127  I 
Membrana  tympani,  429 
Membranous  dysmenorrhea,  S3 

stools,  1097 
Memory,  loss  of,  1265 
Mendel's  sign,  178 
Mendel-Becbterew  reflex,  518 
Menopause,  21 
Menorrhagia,  76 
Menses  : 

appearance  of,  73 

offensive,  82 

sanguineo- purulent,  81 
Menstruation,  73 
Mentality,  precocious,  1264 
Mesenteric  glands,  1639 
Metallic  tinkling,  1729 
Methsemoglobin,  995 
Meteorism,  1700 
Methylene  blue  test,  968 
Metrorrhagia,  76 
Meunier's  sign,  311 
Microblasts,  1454 
Micrococci,  1501-1520 
Microcvtes,  1453 
Micturition,  936-948 

difficult,  942 

diminished  stream,  944 

frequent,  937 

interrupted,  94-4 

involuntary,  938 

painful,  941 

precipitate,  938 
Middle  age,  diseases  of,  20 
Miliaria,  331 
Milk,  abnormal,  771 

in  breasts,  770 
Millard-Gubler  syndrome,  1339 
Mirror- writing,  1260 
Miscellaneous  section,  1803 
Mittelschmerz,  119 
Moebius'  sign,  498 
Monophobia,  1280 
Monoplegia,  brachial,  1330 

crural,  1331 
Moon's  teeth,  632 
Moro's  reaction,  1818 
Motility,  gastric,  1124 
Mouth  : 

bleeding,  596 

drawn,  600 


Mouth 

dribbling,  592 

dry,  598 

fissures  of,  611 

foam  at,  595 

open,  599 

swellings  of,  601 
Moynihan's  test,  17!>7 
Mucus  in  stools,  1099 
urine,  1010 
Mulberry  rash,  345 
Munro's  point,  180 
Murexide  test,  1044 
Murmurs  : 

aneurysmal,  1784 

apex,  1748 

arterial,  1778 

base,  1751 

femoral,  1780 

Flint"  s,  1749 

Potato's,  1741 

subclavian,  1779 

venous,  1772 
Murphy's  sign,  1634 
Muscae  volitantes,  553 
Muscles,  pain  in,  137 
Muscular  hyperalgesia,  191 

hypotonia,  1349 

prominence,  310 

rigidity,  1420 

sense,  208 

wasting,  309 
Musset's  sign,  364 
Mussy's  point,  179 
Mutism,  1236 
Myalgia,  137 
Myasthenic  reaction,  1438 

state,  1440 
Mydriasis,  501 
Mvelocytes,  1466 
Myoidema,  1672 
Myokymia,  1408 
Myosis,  504 

Myotonic  reaction,  1446 
Myxococcidium,  1563 


Nails  : 

brittle,  904 
cyanosed,  903 
grooved,  907 
incurved.  906 


Me-Na 


504 


INDEX 


Nails : 

'reedy,'  911 
shed,  .905 
'  spoon,'  910 
thickened,  908 
ulcers  around,  909 
Narcolepsy,  60 
Nasal  obstruction,  580 
regurgitation,  :585 
vein,  dilated,  575 
voice,  1230 
Nausea,  1114 
Navel  (see  Umbilicus) 
Neck  : 

glands  enlarged,  727-731 
stiff,  710 

swellings  in,  714,  727 
tumefaction  of,  714 
veins  of,  722,  725 
wry,  711 
Negative  symptoms,  1827 
Negri's  corpuscles,  1585 
Nelaton's  line,  848 
Nictitation,  456 
Nightmare,  59 
Night  terrors,  58 

worse  at,  152,  1804 
Nipple  : 

oozing  from,  774 
Paget's,  776 
pigmented,  775 
Nodal  rhythm,  1765 
Nodes,  ulnar,  879 

conjunctival,  478 
Nodules,  cutaneous,  350 

subcutaneous,  846 
Noguchi's  globulin  test,  803 
Noguchi's  luetin  test,  1824 
Non-pitting  oedema,  337 
Normoblasts,  1454 
Nose : 

bleeding  from,  586 
bridgeless,  573 
broadened,  570 
butterfly,  568 
gangrene  of,  574 
potato,  571 
red,  567 
saddle,  572 
swollen.  569 
Nostrils  : 

collapsed,  .578 


Nostrils : 

dilating,  579 

discharge  from,  582-584 

large,  581 

obstructed,  580 
Nothnagel's  sign,  1313 
Nucleated  corpuscles,  1454 
Nucleo-proteid,  953-1008 
Numbness,  215 
Nun's  murmur,  1776 
Nutrition,  307 
Nyctalopia,  551 
Nystagmus,  489 

Cheyne's,  489 
metronome,  489 


Obesity,  308 
Obsessions,  1280 
Obstruction : 

intestinal,  1078 

nasal,  580 
Occipital  glands,  enlarged,  732 
Occupation,  24,  25 

neuroses,  27 
Oculo-cardiac  reflex,  500 
Odour  of  breath,  1199 
CEdema,  335 

blue,  337 

circumscribed,  336 

of  arm,  872 
foot,  863 
legs,  864 
GEsophagoscope,  689 
(Esophagus,  stenosis  of,  688 
Oidium  albicans,  1583 
Old  age,  diseases  of,  22 
Oligocythemia,  1450 
Oliver's  sign,  713 
Omega  melancholicum,  409 
Onset : 

gradual,  41 

sudden,  40 
Ophthalmoplegia,  497 
Ophthalmoscope,  528 
Ophthalmoscopic     appearances, 

530-543 
Opisthotonos,  1426 
Oppenheim's  reflex,  1376 
Oppression,  feeling  of,  229 
Opsiuria,  976 
Opsonic  index,  1494 

Na-Op 


TNDEX 


505 


Optic  atrophy,  539 

neuritis,  538 
Orbit,  enlarged,  494 
Orthopnoea,  1282 
Oscillation  of  head,  3G2 
Otoscope,  430 
Otorrhcea,  428 
Oxalates,  1053 
Ozaena,  583 


Pagano's  reaction,  1817 
Pain,  86 

character  of,  140-153 
determination  of,  85 
dull,  142 
general,  87 
gnawing,  146 
illusional,  195 
increased  at  night,  152 
increased  by  breathing,  151 
increased  by  food,  147 
increased  by  movement,  150 
'lightning,'  138 
muscular,  137 
paroxysmal,  143 
radiating,  144 
referred,  153 
relieved  by  food,  148 
relieved  by  pressure,  149 
sharp,  141 
shifting,  145 
Pain,  regional,  88-140 
in  abdomen,  116-123 
arm,  129 

back,  102 

chest,  108-115 

coccyx,  104 

ear,  95 

epigastrium,  117 

eyeballs,  94 

foot,  134 

forehead,  89-93 

groin,  121 

hand,  130 

head,  89 

heel,  135 

hypochondrium,  113,  114 

hypogastrium,  119 

iliac  region,  120 

interscapular  region,   107 

jaw,  97,  98 


Tain,  regional : 
in  joints,  139 
leg,tl33 

limbs,  138 
loins,  106 
mamma,  109 
neck,  99 
nose,  96 
nucha,  100 
occiput,  90 
pelvis,  119 
penis,  126 
perinseum,  124 
prsecordium,  111 
rectum,  125 
sacrum,  105 
shoulder,  128 
side,  112 
spine,  103 
sternum,  110 
testicle,  127 
thigh,  131 
throat,  101 
umbilicus,  118 
vertex,  92 
Palate  : 

perforated,  639 
swollen,  638 
ulcerated,  637 
white,  636 
Palatine  reflex,  1380 
Pallesthesia,  214 
PaUor,  385 

transient,  386 
Palpation,  1608-1639 

retractive,  1609 
Palpitation,  219 
Pancreatic  reaction,  1038 
Papules,  346 
Paracentesis  : 
cerebri,  805 
lumbar,  798-804 

abdomen,  787-797 
of  chest,  777-786 
pericardii,  784 
Paracusis  Willisii,  436 
Paradoxic  contraction,  1404 
Parsethesise,  215 
Parageusia,  674 
Paragraphia,  1258 
Paralysis  : 

of  third  nerve,  1308 

Op-Pa 


506 


INDEX 


Paralysis  : 

of  fourth  nerve,  1309 
fifth  nerve,  1310 
sixth  nerve,  1311 
seventh  nerve,  1312 
eighth  nerve,  431 
ninth  nerve,  1315 
tenth  nerve,  1316 
eleventh  nerve,  1317 
twelfth  nerve,  1318 
anterior  crural,  1324 
articulation,  1339 
circumflex  nerve,  1322 
deglutition,  1327 
hand,  1330 

intercostal  nerves,  1321 
larynx,  702 
musculo-spiral,  1323 
phrenic  nerve,  1320 
soft  palate,  1329 
sympathetic  nerve,  1319 
sphincters,  939,  1084 
crossed,  1338 

differential  diagnosis  of,  1356 
Paramimia,  1249 
Paramnesia,  1266 
Paraphemia,  1244 
Paraplegia,  1347 
Parasites,  1104 
Parergiae,  1396 
Paresis,  1346 
Parkinson's  mask,  411 
Parosmia,  590 
Parotid,  enlarged,  728 
Parrot's  nodes,  358 
Patellar  clonus,  1388 
Patellar  striae,  327 
Patellar  tap,  1714 
Pathophobia,  1280 
Patients,  varieties  of,  2 
Peau  d' orange,  271,  772 
Pectoriloquy,  1736 
Pectus  carinatum,  742 
Pelvic  tumours,  1621 
Pendulum  rhythm,  1758 
Penis,  ulceration  of,  923 
Pentose,  950,  1014 
Percussion  : 

auscultatory,  1711 
of  abdomen,  1695 
chest  •  1659-1694 
head,  1709 


Percussion  : 

of  limbs,  1712 
spine,  156 
variations  in,  1683 
Perez'  sign,  1741 
Perforating  ulcer,  866 
Perinaeum  : 

swelling  in,  839 
tender,  167 
ulcerated,  840 
Periodicity,  54 
Peristalsis,  visible,  829 
Perspiration,  316 
odorous,  322 
Pes  arcuatus,  858 

cavus,  858 
Petechia,  332 
Phalanges,  necrosis  of,  868 
Pharynx  : 

bulging,  681 
growths  of,  684 
mucus  on,  685 
ulcers  on,  683 
vesicles  on,  682 
Phenyl -hydrazine  test,  949 
Phosphates,  1028 
Photophobia,  561 
Phrenic  phenomenon,  762 
Pfuhl's  sign,  783 
Pica,  70 

Picking  bedclothes,  1417 
Pigeon  breast,  742 
Pigment : 

in  blood,  1474 

buccal  membrane,  617 
skin,  324 
sputa,  1156,  1174 
Piltz'  pupil  sign,  520 
Pirquet's  reaction,  1819 
Placentin  test,  934 
Plaques,  651 
Plasmodia,  1562 
Platelets,  1456 
Pneumaturia,  1041 
Pneumococci,  1510 
Poikilocytosis,  1459 
Point,  Boas'  185 
Erb's,  1447 
McBurney's,  180 
Points  douloureux,  187 
Polariscope,  949 
Pollen  in  sputa,  1171 

Pa-Po 


INDEX 


507 


Polliteer's  tost,  447 
Polyalgeaia,  197 

I V  ■!  ycythaemia,  1451 
Polyopia.  646 
Polyuria,  972,  973 

I'liimim  Adami,  descent  of,  719 
Popliteal  swellings,  862 
Porges-Meier  reaction,  1492 
Post-tussive  suction,  1724 
Posture  sense,  209 
Pott's  curvature,  815 
Pozzi's  syndrome,  1651 
Precordial  anxiety,  221 
bulging,  751 
retraction.  761 
Priapism,  922 
Prolapsus  ani,  1083 
Pronation  sign,  1334 
Propagation  of  disease,  43-47 
Prostatic  threads,  1075 
Prostration,  234 
Prune- juice  serum,  781 

sputa,  1152 
Pterygoid  chest,  741 
Ptosis,  457 
Pudding  face,  403 
Puerile  breathing,  1716 
Pulsating  Liver,  286 
Pulsation  : 

abnormal,  289 

capillary,  288 

epigastric,  287 

in  abdomen,  285 

in  chest,  284 

liver,  286 

retinal,  531 

venous,  269,  283,  725 
Pulse,  240-288 

alternating,   253 

anacrotic,  261 

compressible,  246 

Corrigan's,  250 

dicrotic,  260 

frequent,  241 

full,  247 

hard,  245 

intermittent,  258 

irregular,  258 

irritable,  251 

jerky,  250 

large,  247 

late,  264,  265 


Talse  : 

quick,  241 

respiration  ratio,  267 
Riegel's,  257 
slow,  242   .j 
small,  248 
soft,  246 
sustained,  249 
tardy,  244 

temperature  ratio,  268 
thrilling,  252 
venous,  269,  283 
water-hammer,  250 
weak,  246 

on  one  side,  262 
in  post-tibials,  263 
Pulsus  alternans,  253 
bigeminus,  254 
bisferiens,  255 
celer,  250 
paradoxus,  256 
Pupil  reflex  : 

accommodation,  515 
Argyll-Robertson,  516 

reversed,  517 
cilio -spinal,  522 
Bechterew's,  518 
Bumke's,  523 
Gifford's,  521 
light,  509 
Piltz,  520 
Westphal's,  519 
Pupils  : 

contracted,  504-505 
dilated,  502-503 
irregular  margin,  506 
sluggish,  509 
Pus  in  fluid  aspirated,  780 
stools,  1094 
urine,  1047 
Pustules,  349 
Putnam's  sign,  851 
Pyrexia,  295,  296 
Pyrosis,  1123 
Pyuria,  1047 


Quarantine  after  fevers,   &c. , 

48-50 
Quincke's  sign,  912 
Quinquaud's  sign,  1409 

Po-Qu 


508 


INDEX 


Radium  rays,  1814 
Rainbow  vision,  554 
Rales : 

crepitant,  1731 
deglutition,  1731 
sibilant,  1727 
sonorous,  1726 
subcrepitant,  1731 
Ramond's  sign,  811 
Rarity,  excluded  by,  1828 
Rash,  duration  of,  52 
Raspberry  crusts,  352 
Reaction  of  degeneration,  1437 
Flora's,  1438 
Ghilarducci's,  1442 
Jolly's,  1439 

Rumpf's,  1441 
Rectal  examination,  1640 
incontinence,  1084 
Recti,  divarication  of,  826 
Rectum,  ballooning  of,  1641 
Rectus,  rigid,  827 
Reder's  sign,  1642 
Reduplication,  1761 
Reeling  gait,  1295 
Reflex  : 

abdominal,  1363 

adductor,  1385 

Babinski's,  1373 

Bechterew's,  1365 
pupil,  518 

Brissaud's,  1379 

bulbo-cavernous,  1368 

consensual,  510 

corneal,  470 

cremasteric,  1366 

cutaneous,  1360-13S2 

dartos,  1367 

epigastric,  1362 

Geigel's,  1369 

gluteal,  1371 

Gordon's,  1375 

Hirschberg's,  1378 

interscapular,  1370 

jaw,  1395 

knee,  1382-1384 

MacCormac's,  1384 

Mendel's,  1387 

Oppenheim's,  1376 

palate,  1380 

plantar  extensor,  1373-1376 

pupillary,  508-524 


Reflex : 

Rosenbach's,  1364 
Rossolimo's,  1377 
scapulo-humeral,  1391 
Schafer's,  1374 
supinator,  1392 
tendinal,  1381 
tendo  Achillis,  1386 
triceps,  1392 
wrist,  1394 
Reflex  arc,  1358 
Regurgitation,  1116 
Remak's  sign,  193 
Resistance,  sense  of,  1671 
Resonance  : 

abnormal,  1673 
amphoric,  1676 
skodaic,  1675 
Restlessness,  56 
Retching,  1114 
Retention  of  urine,  940 
Retina : 

black  patches,  532 
contracted  arteries,  535 
dilated  veins,  534 
disc  blurred,  541 
disc  cupped,  540 
shadow  sign,  537 
silver  wire  arteries,  536 
white  patches,  533 
Retinal  haemorrhage,  530 

pulsation,  531 
Retracted  abdomen,  823 
Retraction,  epigastric,  850 
episternal,  718 
of  interspaces,  760 
of  lower  ribs,  762 
precordial,  761 
Retropulsion,  1300 
Reusner's  sign,  1655 
Revilliod's  sign,  1312 
Rhinorrhcea  : 
blue,  584 
mucous,  582 
purulent,  583 
watery,  582 
Rhonchal  fremitus,  1590 
Rhonchus,  1726 
Rib,  extra  floating,  763 
Ribs,  retraction  of,  762 
Rigidity,  827,  1420 
waxy,  1423 

Ra-Ri 


INDEX 


r,<  19 


Rigors,  236 

recurring,  238 

Rinne  : 

negative,  444 

positive,  443 
Risus  sardonicus,  41 G 
Rivalta's  sign,  797 
Romberg's  sign,  1304 
Rontgen  rays,  1811 
Rosary  chest,  746 
Rosenbach's  sign,  1364 
Ross-Jones'  test,  802 
Rotary  twist  of  spine,  817 
Rotch's  sign,  1668 
Rothschild's  sign,  759 
Rumination,  1116 
Rumpel-Lerde's  test,  334 
Rumpf's  reaction,  1441 


Sabre  shin,  854 
Saccadee,  respiration,  1717 
Saddle  nose,  572 
Sahli's  reaction,  969 

whistle,  1799 
Salaam  spasm,  1413 
Saliva : 

acid,  594 

diminished,  593 

thickened,  592 
Salivation,  592 
Sallowness,  390 
Saloman's  test,  1109 
Saltatory  spasm,  1412 
Sander's  sign,  1607 
Sanger's  pupil,  513 
Sansom's  sign,  1761 
Santini's  booming,  1711 
Sarcina  ventricuH,  1520 
Saundby's  test,  1085 
Scabs,  352 
Scalp  : 

cedematous,  366 

swellings  on,  359 

tender,  155 
Scapula,  prominent,  741,  809 
Scapulo-humeral  reflex,  1391 
Scarpa's   triangle,    swellings   in, 

850 
Scars,  diseases  leaving,  343 
Schafer's  reflex,  1374 
Schapiro's  test,  270 


School  quarantine,  48-50 
Schuele's  sign,  409 
Schuller's  side-gait,  1302 
Schwa  bach's  test,  449 
Sclerotic  : 

black,  473 
blue,  475 
pearly,  472 
yellow,  474 
Scoliosis,  814 
Scotoma,  550 
Scrotal  fistula,  930 
Scrotum,  swollen,  929 
Scybala,  1088 
Seal -fin  deformity,  883 
Season,  1803 
Sedentary  occupation,  25 
Sediments  in  urine,  1043 

brickdust,  1045 

microscopic,  1047 

white,  1046 
Semon's  sign,  708 
Sensation,  85-230 
Sensation  tests,  199 
Sensibility,  85 
Sergent's  white  line,  326 
Serum  tests,  1484,  1492 
Sex,  12,  13 

Sexual  power,  loss  of,  927 
Shiverings,  237 
Shoulder,  raised,  876 

swellings,  875 

wasted,  309 
Shreds  in  menstruation,  83 
Shrieks,  1232 
Sibilant  rale,  1727 
Sibilus,  1727 
Sighing,  1208 
Signe  du  sou,  1677 
Signorelli's  sign,  174 
'  Silver  fork  deformity,'  880 
Simon's  sign,  1216 
Singultus.  1416 
Sinking  feeling,  221 
Skew  squint,  495 
Skin,  313 

bronzed,  324 

clammy,  315 

dry,  314 

eruptions,  345-350 

glossy,  341 

goose-skin,  340 

Ri-Sk 


510 


INDEX 


Skin : 

inelastic,  339 

parasites  of,  356 

petechial,  332 

pigmented,  324 

red,  330 

scaling,  342 

scarred,  343 

thickened,  329 

white  patches,  328 

yellow,  323 
Skodaic  resonance,  1675 
Slaty  anaemia,  389 
Sleep,  55 
Sleeplessness,  57 
Smell,  sense  of,  587-590 

subjective,  590 
Smile,  nasal,  407 

transverse,  416 
Smith's  (Eustace)  sign,  1777 
Snail-track  ulcer,  683 
Sneezing,  576 
Snoring,  1206 

Solovieff's  phenomenon,  762 
Sonorous  booming,  1711 
Sordes,  624 
Sound,  uterine,  1650 
Spaces,  intercostal,   759-761 
Spade  hand,  886 
Sparks,  subjective,  559 
Spasm  : 

clonic,  1406-1417 

tonic,  1418-1433 

of  inspiration,  1428 
larynx,  1429 
sterno-mastoid,  1430 
swallow,  1427 
toes,  1431 
Spastic  gait,  1293 

contractions,  1419 
Spasticity,  1306 
Specular  examination,  1643 
Speech  : 

indistinct,  1237 

interrupted,  1238 

lost,  1236 
Spermatorrhoea,  925 
Spermatozoa,  927 
Sphygmograms,  276 
Sphygmograph,  276 
Sphygmometer,  271 
Spinach  stools,  1090 


Spinal  cord,  1357 

curvatures,  812-815 

stiffness,  806 

swellings,  810 

tenderness,  156 
Spine,  rotation  of,  817 
Spirilla,  1564 
Spirochaetae,  1567 
Splashing : 

heart,  1768 

lung,  1742 

stomach,  1794 
Spleen,  displaced,  1636 

enlarged,  1635    , 

palpation  of,  1610 
Splenic  dullness,  1660 
Spring,  diseases  of,  1803 
Sputa  : 

albuminous,  1163 

bacilli  in,  1181-1187 

bilious,  1161 

blood  in,  1148,  1149 

blue,  1160 

casts  in,  1155 

cocta,  1145 

cruda,  1144 

currant- jelly,  1151 

elastic  fibres  in,  1140,  1169 

fetid,  1162 

frothy,  1142 

gooseberry,  1157 

greenish,  1161 

hairs  in,  1191 

microscopic  characters, 

1165-1190 

muco- purulent,  1145 

mucous,  1144 

nummular,  1146 

organisms  in,  1175-1190 

prune-juice,  1152 

purulent,  1147 

rusty,  1150 

scanty,  1141 

soapsud,  1142 

viscid,  1143 

wine  froth,  1142 
Squint,  495 
Staphylococcus,  1502 
Starting  in  sleep,  59 
Stature,  312 
Stellwag's  sign,  461 
Stenson's  duct,  619 

Sk-St 


INDEX 


511 


Sterility,  female,  935 
Sterno- mastoid  : 

prominent,  717 

swelling  in,  716 
Sternum,  sunken,  756 
Stigmata,  397 
Stiller's  sign,  763 
Stocker's  sign,  1289 
Stokes'  Law,  1307 

sign,  1754 
Stomach  splash,  1796 

tests,  1792 
Stools  : 

amoebae  in,  110S 

bacilli  in,  1108 

bilharzia  in,  1108 

blood  in,  1096 

'butter'  1100 

cestodes  in,  1106 

concretions  in,  1102 

crystals  in,  1108 

fat  in,  1100 

flattened,  1086 

food  in,  1101 

green,  1090 

indol  in,  1098 

'  meat  washings,'  1096 

membranes  in,  1097 

microscopic  examination  of, 
1108 

mucus  in,  1099 

offensive,  1093 

orange- juice,  10S9 

nematodes  in,  1105 

pale,  1089 

parasites  in,  1105 

pea-soup,  1089 

pipe-like,  1087 

porridge,  1089 

pus  in,  1094 

sand  in,  1103 

scybala  in,  1088 

serous,  1092 

slate  colour,  1091 

tarry,  1095 

trematodes  in,  1107 
Strabismus,  495 
Straining,  113 
Strangury,  942 

Strawberry- cream  blood,  1480 
Streptococci,  1503 
Streptothrix  madura?,  1575 


SI  i  ia>,  atrophic,  327 

Stridor,  327 

Stri'impel's  phenomenon,  1405 

Sturges'  carditis,  1769 

Stupor,  62 

Subclavian  murmur,  1779 

Submaxillary   glands,    enlarged, 

729 
Subsultus,  1407 
Succussion  sound,  1742,  1797 
Sudamina,  331 
Sugar  in  urine,  949,  1012 
Summer  diseases,  1803 
Supinator  jerk,  1392 
Suppression  of  urine,  945 
Supraclavicular       glands,       en- 
larged, 730 
Supracondyloid  gland,  877 
Sutures,  broad,  373 

overlapping,  374 
Swallow,  the,  692 

spasm  of,  1427 
Swallowing  sound,  1789 
Sweat,  abnormal,  321 
Sweating,  316-332 

bloody,  319 

chylous,  318 

coloured,  320 

general,  316 

odorous,  322 

partial,  317 

sensation  of,  224 
Symmetrical       lung       diseases, 

1744 
Symptoms — Complex,  1829 
Syncinesia,  1354 
Synonyms,  1830 


Tache  cerebrale,  325 
Tachypncea,  1223 
Tactile  fremitus,  1588 
Tailor's  rotation,  920 
Tapir  lip,  608 
Tarry  stools,  1095 
Taste,  672 

foul,  675 

lost,  673 

perverted,  674 
Teeth,  carious,  627 

conical,  631 

dentated,  630 


St-Te 


512 


INDEX 


Teeth : 

early,  634 
grinding  of,  626 
Hutchinson's,  631 
laminated,  629 
late,  635 
loose,  628 
Moon's,  632 
notched,  631 
screw-driver,  631 
sordes  on,  624 
Temper,  change  of,  1277 
Temperature,  290-306 
continued,  298 
differential,  306 
hectic,  299 
how  to  take  the,  291 
hyperpyrexial,  297 
intermittent,  301 
inverse  remittent,  300 
local  lowering  of,  293 
local  raising  of,  294 
raised,  295,  296 
remittent,  298 
sense,  211-213 
septic,  299 
'  spiked  chart,'  ,302 
subnormal,  292 
sudden  invasion  of,  305 
terminations  of,  303,  304 
Tender  spots,  172-185 
Tenderness,  154 

estimation  of,  154 
in  abdomen,  162-168 

chest,  158 

epigastrium,  163 

feet,  170 

hypochondrium,  160,  161 

hypogastrium,  166 

iliac  region,  164 

joints,  171 

limbs,  169 

liver,  160 

lumbar  region,  157 

mamma,  159 

McBurney's  point,  180 

perinseum,  167 

scalp,  155 

spine,  156 

spleen,  161 
Tendo-Achillis  jerk,  1386 
Tendon  reflexes,  1381 


Tenesmus  : 

rectal,  1081 

vesical,  942 
Tension  : 

arterial,  271-274 

ocular,  525-527 
Test  meal,  1111 
Testicle  : 

pendulous,  928 

swollen,  926 
Thermesthesia,  211-213 
Thermometric  scales,  291 
Thirst,  71,  72 
'  Thorax  en  bateau,'  756 
Thrill: 

cardiac,  1592 

epigastric,  1596 

hydatid,  1678 
Throat,  swollen,  678 
Throbbing  carotids,  721 

sensation,  225 
Thymus,  enlarged,  735] 
Thyroid  gland  : 

enlarged,  733 

shrunken,  734 
Tibialis  phenomenon  1405 
Tic-tac  rhythm,  1758 
Time  of  year,  1803-1809 
Tingling  sensation,  218 
Tinnitus  aurium,  438 
Toe: 

spasm  of,  1431 

swollen,  861 
Toe  reflex,  1373-1376 
Tomato-growths,  352 
Tongue : 

bitten,  658 

black,  653 

brown,  645 

deviating,  662 

dry,  642,  643 

fissured,  656 

furred,  644,  646 

'  geographical,'  665 

glazed,  642 

hairy,  652 

immobile,  663 

indented,  647 

large,  647 

leukoplakia  of,  667 

nodular,  659 

one-sided  furring  of,  646 

Te-To 


INDEX 


513 


Tongue : 

one-sided  protrusion  of,  662 

pale,  647 

papillitis,  669 

patches  on,  670,  671 

pigment  on,  654 

plaques  on,  651 

psoriasis,  651 

raw  beef,  650 

scarred,  658 

sclerosis,  668 

small,  656 

smoker's  patch  on,  666 

strawberry,  664 

swollen,  648 

trembling,  661 

tumours  of,  660 

ulcerated,  657 

white  fur  on,  644 
Tonsils  : 

plaques  on,  680 

red,  677 

swollen,  678 

ulcerated,  680 

white  patches  on,  679 
Tophi  in  ears,  419 

eyelids,  455 
Torticollis,  711 
Tortuous  radials,  266 
Trachea,  displaced,  712 
Tracheal  tug,  713 
Trade  diseases,  24-27 
Trapp's  test,  960 
Traube's  space  dull,  1666 
Trelat's  nsevi,  333 
Trembling,  1407 
Tremor,  1407 

intention,  1410 
Tresilian's  sign,  619 
Triceps  reflex,  1392 
Trichterbrust,  755 
Trismus,  1424 
Trochanter,  displaced,  848 
Trochanter  tap,  1713 
Trochlear  gland  enlarged,  877 
Tropical  diseases,  1810 
Trousseau's  phenomenon,  1432 
Trypanosoma,  1581 
Tube,  auscultation,  430 
Tubercle  bacillus,  1553 
Tubercles  on  choroid,  542 
Tubercles  on  skin,  350 


2  L 


Tuberculin  tests,  1815,  1822 
Tubular  breathing,  1721 
Tumefaction     above     clavicles, 

714 
Tumours  : 

abdominal,  1616-1626 

fixed  on  palpation,  1623 

fluctuating,  1618 

movable  on  palpation,  1622 

moving     with     respiration, 
1624 

pelvic,  1621 

wandering,  1625 
Tuning-fork,  440-450 

sign,  1743 
Tiirgensen's  sign,  1731 
Twitching,  405,  1407 
Tympanites,  1700 
Tympanitic  note,  1674 
Typhic  or  typhoid  state,  62 


Uffelmann's  test,  1112 
Ulcers  : 

varieties  of,  354 

penile,  923 

perforating,  866 
Ulnar  nodes,  879 
Umbilicus  : 

displaced  upwards,  830 

fixed,  833 

oozing  from,  835 

projecting,  834 

retracted,  831 

stretched,  832 

varicose,  836 
Unconsciousness,  65 

momentary,  66 
Unilateral  headache,  91 
Ureteral  jets,  947 
Urethral  discharge,  924 
Unschuld's  sign,  1418 
Urination,  936-948 
Urine,  the  : 

acetone  in,  966,  1018 

air  in,  1041 

albumen  in,  951,  1004 
Bence-Jones,  955,  1006 
postural,  1005 

albumose  in,  954,  1007 

alkaline,  981 

To-Ur 


514 


INDEX 


Urine,  the : 

amphoteric,  980 

bacilli  in,  1060 

bile  in,  958,  1021 

bilharzia  in,  1063 

black   994 

blood' in,  962,  1000-1001 

blue,  988 

Bouchard's  coefficient,  1036 

brickdust  sediment,  1044 

brown,  994 

calculi,  1046 

Cammidge's  reaction,  1037 

Cathelin's  separator,  971 

casts  in,  961,  1064-1073 

chlorides  in,  1030 

cholestearin  in,  1054 

clots  in,  1003 

cylindroids  in,  1074 

cystin  in,  1056 

desmoid  reaction  of,  969 

diacetic     acid,     in,      967- 

1019 
diastase  in,  1038 
diminished,  975 
distoma  in,  1063 
effervescence  of,  1043 
egg  yellow,  1034 
Ehrlich's  reaction,   965, 

1033 
elastic  fibres  in,  1051 
epithelium  in,  1049 
Esbach's  test,  952 
faeces  in,  1040 
fat  in,  1050 
fibrinuria,  1009 
freezing      point      of,      970, 

1039 
frothy,  997 
green,  939 

growth  particles  in,  1048 
high  colour,  987 
hippuric  acid  in,  1027 
hooklets  in,  1062 
incontinence  of,  938,  939 
increased,  973,  974 
indican  in,  1022 
inosite  in,  1016 
Jaksch's  spirals  in,  1076 
kreatinin  in,  1011 
lactose  in,  1015 
itevulose  in,  1013 


Urine,  the : 

lead  in,  959 

leucin  in,  1055 

methylene  blue  test,  968 

milky,  9)6 

mucus  in,  1010 

nocturnal  increase  of,  974 

non-decomposing,  999 

nucleo  -  proteid      in,      953, 
1008 

odorous,  998 

oxalates  in,  1053 

opalescent,  990 

pale,  986 

pentose  in,  950,  1014 

peptone  in,  1008 

phloridzin  test,  1035 

phosphates  in,  1028 

pigment  in,  1052 

pink,  991 

prostatic  threads  in,  1075 

pus  in,  964,  1047 

quantity  of,  972-976 

reaction  of,  977-981 

reddish,  992 

retention  of,  940 

sediment  in,  1043 

analysis  of,  1043,  1045 
microscopic,  1047 

smoky,  995 

solids  in,  960 

specific    gravity    of,     982- 
984 

spermatozoa  in,  1058 

stream,  small,  943 

subacid,  979 

sugar  in,  949,  1012 

sulphates  increased  in,  1032 

superacid,  978 

suppression  of,  945 

testicle  casts  in,  1073 

tests  for,  949-971 

torulae  in,  1061 

urea  in,  956,  1023 

uric  acid  in,  957,  1025 

urobilin  in,  985 

uryhaematin  in,  963 

violet,  993 
Uterine  sound,  1650 
Uterus,    examination    of,   1643 

enlarged,  1649 

painful  on  movement,  1648 

Ur-Ut 


